Failure to Monitor and Document Urine Output for Resident with Foley Catheter
Penalty
Summary
The facility failed to adequately monitor and document urine output for a resident with a history of neurogenic bladder and an indwelling Foley catheter. Despite physician orders to monitor urine output every shift, there were multiple instances where no output was recorded, and the intake record could not be provided by the facility. Interviews with staff confirmed that urine output was to be recorded and reported, but documentation was incomplete, and the facility was unable to produce intake records for the period in question. Additionally, the facility's policy on bowel and bladder management did not provide clear guidance on these procedures. The resident involved had diagnoses including a nondisplaced sacral fracture and neuromuscular dysfunction of the bladder, requiring close monitoring of urinary function. Family members reported concerns about the lack of documentation and absence of bladder scans when the Foley catheter was not in place. The Director of Nursing acknowledged the importance of accurate intake and output documentation but was unable to provide the necessary records, citing limitations in record access after 30 days. These actions and omissions resulted in a failure to properly monitor and communicate episodes of low urine output to the physician.