Incomplete Documentation of Urinary Catheter Output
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident who had a Foley catheter in place. According to the facility's policy, staff were required to record urinary output amounts for residents with catheters at the end of each shift and document this information in the resident's medical record. For this resident, who was admitted with diagnoses including Neurologic Neglect Syndrome, urine retention, and a history of stroke, there were multiple instances where urine output was not documented as required. Specifically, there was no documentation of urine output during certain day and night shifts over a one-week period, despite physician orders and care plan interventions that called for this monitoring. Observations confirmed the presence of a Foley catheter and the use of a privacy bag for the urinary drainage bag. Interviews with nursing staff and the unit manager revealed that documentation of urine output was incomplete and not maintained for every shift as required. The unit manager acknowledged the gaps in documentation and emphasized the importance of recording urine output to monitor for urinary retention. The lack of documentation meant that staff could not verify the resident's urinary output on the days when records were missing.