Failure to Document Urinary Output for Resident with Indwelling Catheter
Penalty
Summary
The facility failed to document urinary output as ordered for one resident who had an indwelling catheter. According to the facility's own policies, residents with indwelling catheters are to have their urinary output assessed and documented at regular intervals. The resident in question was admitted with diagnoses including venous insufficiency and polyuria, and was cognitively intact. Physician orders and the resident's care plan specifically required monitoring and documentation of urinary output each shift. A review of the Treatment Administration Records (TAR) for April and May revealed multiple instances where the resident's urinary output was not documented as required. Specifically, there were missing entries for several shifts across both months. During an interview, the unit manager confirmed that staff should have been documenting the output as ordered, but this was not consistently done.