Failure to Notify Physician of Low Urine Output in Resident with Foley Catheter
Penalty
Summary
The facility failed to follow its policy and procedure regarding physician notification for a resident with a Foley catheter who experienced episodes of low urine output on multiple shifts. The resident, admitted with a nondisplaced sacral fracture and neuromuscular bladder dysfunction, had a Foley catheter in place for neurogenic bladder. Documentation showed inconsistent and sometimes missing records of urine output, with several shifts lacking any recorded output. Despite a physician order to monitor urine output every shift, there were instances where low or absent output was not communicated to the physician as required by facility policy and the physician's expectations. Interviews with nursing staff, the resident's family member, and the physician confirmed that the physician was not notified of low urine output, even though the physician stated that outputs less than 250 ml required notification. The family member also reported that voiding was not documented and a bladder scan was not performed when the Foley catheter was removed and later reinserted. The facility's policy required prompt notification of the physician for significant changes in a resident's condition, but this was not followed in the case of this resident's urinary output.