Incomplete Documentation of Urine Monitoring for Catheterized Resident
Penalty
Summary
The facility failed to ensure that the medical record for one of six sampled residents was complete, specifically regarding documentation of urine characteristics for a resident with an indwelling urinary catheter. According to the facility's policy and procedure for catheter care, information such as urine color, clarity, and odor should be recorded in the resident's medical record to prevent catheter-associated complications. Medical record review revealed that the Treatment Administration Record (TAR) for August was incomplete, with missing documentation on two shifts where monitoring of urine characteristics was required by physician order. Interviews with two LVNs confirmed that the TAR entries for the specified dates and shifts were left blank, indicating that documentation was not completed. Both LVNs acknowledged that monitoring may have been performed but was not recorded as required. The Director of Nursing stated that the expectation was for licensed nurses to follow physician orders, and both the Administrator and DON acknowledged the findings during the survey.