Failure to Monitor Urinary Output and Manage Pain per Physician Orders
Penalty
Summary
Staff failed to adequately monitor and assess urinary output and did not ensure pain was assessed and managed according to physician orders for two residents. For one resident with a Foley catheter, there were repeated instances of dark, bloody, and cloudy urine with clots, and staff did not irrigate the catheter tubing as needed. The resident was hospitalized twice, first for a urinary tract infection and later for sepsis, acute kidney injury, and diabetic ketoacidosis. Medical record reviews showed a lack of documentation regarding urinary monitoring, assessment, and timely notification to the physician about catheter blockage and changes in urine. A urinalysis ordered by the nurse practitioner was not collected, and staff interviews revealed inconsistent assessment and monitoring of urinary output. Another resident with liver cell carcinoma had a physician's order for pain evaluation every shift and PRN morphine for comfort care. Documentation showed that pain assessments were not consistently completed as ordered, with a gap of several days without any pain assessment recorded. Morphine was administered only sporadically, and there was no documentation explaining the lack of pain assessments or administration of PRN medication during the specified period. Staff interviews confirmed that pain assessments and documentation were not performed as required by the physician's orders. These deficiencies were identified through interviews, observations, and record reviews, and were acknowledged by facility staff, including the DON and unit manager. The lack of proper monitoring, assessment, and documentation directly contributed to the residents' unmet care needs and hospitalizations.