Failure to Perform and Document Physician-Ordered Urinary Retention Monitoring
Penalty
Summary
A deficiency occurred when a resident with a history of urinary retention and diagnoses of obstructive and reflux uropathy did not receive a physician-ordered treatment for monitoring and managing urinary retention. The resident had an order for post void residual (PVR) bladder scans every shift, with instructions for straight catheterization if the residual exceeded 500 ml. On one night shift, there was no documentation in the medical record or Medication Administration Record (MAR) to indicate that the PVR was performed, nor was the amount of urine retained recorded, as required by the physician's order and facility policy. Interviews revealed that the nurse preceptor on duty was supervising a new graduate nurse on orientation. The preceptor was unaware if the PVR was completed and acknowledged that if it had been done, it would have been documented accordingly. The Staff Development Coordinator confirmed that the preceptor was responsible for ensuring all treatments and documentation were completed as ordered. The Director of Nurses also stated that proper documentation would have been present if the PVR had been performed. The lack of documentation and uncertainty about whether the ordered treatment was provided constituted a failure to meet professional standards of practice.