Failure to Provide Catheter Care and Monitor Urine Output as Ordered
Penalty
Summary
Staff failed to perform urinary catheter care and monitor urine output as ordered by physicians for two residents with urinary catheters. One resident with urinary retention and obstructive and reflux uropathy had physician orders and a care plan directing foley catheter care each shift, but review of the treatment administration record (TAR) showed that catheter care and output monitoring were not completed on multiple specified shifts. The Director of Nursing confirmed that catheter care was not performed on the dates listed, and facility policy required care every shift and as needed. Another resident with dementia and obstructive and reflux uropathy had orders for suprapubic catheter care each shift, later changed to monitoring foley output every shift. Review of the TAR for several months revealed that staff did not complete catheter care or monitor output on numerous shifts. The Director of Nursing verified these omissions, and facility policy also required catheter care every shift and as needed. These findings were confirmed through record review and staff interview.