Failure to Monitor and Document Catheter Output and Assess for Complications
Penalty
Summary
The facility failed to provide care and treatment consistent with professional standards of practice for residents with indwelling Foley and suprapubic catheters, resulting in inadequate monitoring and documentation of urinary output, as well as insufficient assessment and provider notification when abnormal findings were present. For three residents with catheters, there were repeated instances where urine output was either not documented, documented as zero without further assessment, or recorded with unclear or missing amounts. In multiple cases, there was no evidence that the provider was notified when urine output was absent for a shift, as required by physician orders and facility policy. One resident with a suprapubic catheter experienced two days of increased incontinence and lack of catheter drainage, which was not properly assessed or reported. The resident was ultimately transferred to the hospital and admitted with a severe urinary tract infection. Review of the medical record showed multiple shifts with zero urine output documented and no corresponding provider notification or additional nursing assessments, such as checking catheter patency, vital signs, or abdominal assessment. Interviews with nursing staff revealed a lack of clear parameters for when to notify providers and inconsistent understanding of required assessments when abnormal output was noted. For two other residents with indwelling catheters, similar deficiencies were observed. Documentation of urinary output was frequently missing, incomplete, or unclear, and there was no evidence of provider notification or further assessment when output was zero or not recorded. Facility policies and professional standards require accurate monitoring and reporting of catheter output to prevent complications, but these were not consistently followed, as evidenced by the surveyor's review of records and staff interviews.