Failure to Assess and Document Urine Characteristics for Catheterized Resident
Penalty
Summary
A deficiency occurred when a resident with an indwelling urinary catheter did not receive proper care and services as required by physician orders. The resident, who had diagnoses including atherosclerotic heart disease, Alzheimer's disease, and osteoporosis, was cognitively impaired and required maximum assistance for daily activities. Physician orders specified that the resident's urine color and consistency should be assessed every shift. However, interviews and record reviews revealed that staff failed to document or perform these assessments from the time of the resident's readmission until the deficiency was identified. Both the Medication Administration Record and Progress Notes lacked documentation of urine assessment, and staff confirmed that monitoring was not initiated as ordered. The facility's policy required monitoring and reporting of changes in urine characteristics to prevent infection, but this was not followed. Multiple staff members, including nurses and the DON, acknowledged that the physician's order for urine assessment was not carried out or documented as required. The failure to assess and document urine color and consistency was confirmed through interviews and record reviews, and the DON stated that this omission could delay notification of changes in condition to the physician.