Incomplete Documentation of Urine Output for Catheterized Resident
Penalty
Summary
The facility failed to ensure that the medical record for one resident was complete and accurate, specifically regarding the documentation of urine output for a resident with an indwelling urinary catheter. According to the facility's policy on Output Measuring and Recording, urine output should be recorded in milliliters in the resident's medical record every shift. However, a review of the resident's Treatment Administration Record (TAR) revealed missing documentation of urine output on several dates and shifts, despite physician orders requiring intake and output monitoring every shift and catheter care. During interviews, both a registered nurse and the Director of Nursing confirmed the presence of the indwelling catheter and acknowledged the incomplete documentation. They verified that the nurses were responsible for measuring and recording the urine output in the TAR, and confirmed the specific dates and shifts where documentation was missing. The administrator also verified these findings during a subsequent interview.