Failure to Document Catheter Output as Ordered
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to ensure that a resident with an indwelling catheter had their urine output documented every shift as ordered by the physician. The resident, who had a diagnosis including neuromuscular dysfunction of the bladder, had a physician's order requiring staff to monitor and record catheter output each shift. Review of the medication administration records for August and September revealed multiple instances where urine output was not documented on specified day and night shifts. Staff confirmed that physician orders are required to be followed, and facility policy also mandates adherence to physician orders to provide essential care.