Failure to Accurately Document Urine Output for Resident with Indwelling Catheter
Penalty
Summary
The facility failed to maintain accurate documentation of urine output for a resident with an indwelling catheter, as required by both physician orders and facility policy. The resident, who was admitted with urinary retention and had severe cognitive impairment, was dependent on staff for all activities of daily living and required close monitoring of urinary output. The physician's order specified that urine output should be recorded in milliliters every shift for 30 days. Upon review of the urine output task log and Medication Administration Record (MAR) for the specified period, multiple discrepancies and omissions were identified. There were several shifts where no urine output was documented, and in some instances, the output was recorded as zero without explanation. Additionally, inconsistencies were found between the amounts recorded by CNAs in the task log and those entered by licensed staff in the MAR, with some entries reflecting only the frequency of urination rather than the required volume in milliliters. Interviews with CNAs, LVNs, and the Director of Nursing confirmed that the documentation practices did not align with facility policy or physician orders. Staff acknowledged that accurate and complete documentation of urine output is necessary for monitoring the resident's condition, but failed to consistently communicate and record the required information. The facility's policy emphasized that all services provided to residents must be objectively, completely, and accurately documented to facilitate communication among the interdisciplinary team.