Failure to Document Intake and Output for Resident with Foley Catheter
Penalty
Summary
The facility failed to follow the written care plan for a resident who had a Foley catheter and was experiencing low urine output. The care plan, initiated upon admission, included an intervention to observe and document intake and output according to facility policy. Interviews with nursing staff indicated that Certified Nursing Assistants (CNAs) were responsible for emptying the urinary bag, recording the output, and informing the charge nurse of the total urine output at the end of each shift. However, when documentation was requested, the Director of Nursing (DON) was unable to provide any records of the resident's intake and urine output, stating that it was past the 30-day period since the resident's admission and discharge. A review of the facility's policy confirmed that each patient's care plan should be implemented according to their needs, including the documentation of intake and output. Despite staff statements that output was being recorded, there was no evidence or documentation available to verify that the resident's intake and urine output had been monitored as required by the care plan. This lack of documentation constituted a failure to implement the care plan as written for the resident with a Foley catheter and neuromuscular bladder dysfunction.