Failure to Monitor Urinary Output and Obtain Catheter Orders
Penalty
Summary
The facility failed to ensure proper monitoring and documentation of urinary output for three residents with indwelling urinary catheters or nephrostomy tubes, as required by facility policy. For one resident with moderate cognitive impairment and a foley catheter, there was no documented evidence that staff measured or recorded urine output, despite care plan instructions to report changes in urine characteristics. Another resident with a nephrostomy tube and diagnoses including heart failure had multiple shifts where urinary output was not documented, as confirmed by review of clinical records and interview with the Director of Nursing. Additionally, a third resident with moderate cognitive impairment and an indwelling urinary catheter did not have a physician's order for the catheter or for catheter care documented in the clinical record. Observations confirmed the presence of the catheter and drainage bag, but there was no evidence of urine output monitoring or documentation of catheter care. The Director of Nursing confirmed the lack of required documentation and physician's orders for these residents.