Failure to Document and Treat Hematuria Following Hospital Discharge
Penalty
Summary
The facility failed to ensure that a resident received care for hematuria, a diagnosis documented on the hospital discharge paperwork. Upon admission, the resident's record did not include hematuria as a diagnosis, and subsequent documentation—including the care plan, Minimum Data Set (MDS), and provider progress notes—lacked any reference to treatment or monitoring for hematuria. Despite the hospital discharge instructions specifying care for hematuria, the facility did not incorporate this diagnosis into the resident's plan of care or active diagnoses list. The MDS Coordinator confirmed that hematuria was omitted from the MDS because the facility was not treating the condition in-house, and the Director of Nursing acknowledged that staff failed to document the diagnosis and complete a urinalysis as ordered. The resident experienced a significant decline in condition, including decreased food and fluid intake, increased confusion, general weakness, urine retention, and severe abdominal pain. The resident was readmitted to the hospital with hematuria as the primary diagnosis and later returned to the facility, where blood in the urine was again observed and a urinalysis was ordered but not obtained. Throughout this period, there was no documentation of treatment for hematuria in the provider notes, and the care plan remained incomplete regarding this diagnosis.