Failure to Monitor Intake and Output for Resident with Urinary Retention
Penalty
Summary
A deficiency was identified regarding the facility's failure to monitor and document daily fluid intake and urine output for a resident diagnosed with urinary retention and requiring an indwelling urinary catheter. The resident, who was severely cognitively impaired and had diagnoses including vascular dementia, cerebral infarction, neuromuscular dysfunction of the bladder, and retention of urine, was admitted with an indwelling urinary catheter. The care plan specified that intake and output should be monitored and documented per facility policy. Despite these requirements, review of the medical record revealed that from the time the resident had the indwelling catheter and after its discontinuation, there was no documentation of daily fluid intake or urine output. This lack of monitoring occurred even after the resident experienced a change in condition, was sent to the emergency room, and returned with a Foley catheter in place. The deficiency was confirmed by the Director of Nursing, who acknowledged that intake and output should have been documented and monitored for this resident due to the diagnosis of urinary retention.