Failure to Monitor Catheter Output and Prevent UTIs
Penalty
Summary
The facility failed to ensure that a resident who was incontinent of bladder and had an indwelling catheter received appropriate treatment and services to prevent urinary tract infections (UTIs) and to restore continence to the extent possible. Specifically, the resident's urine output was not monitored and documented as ordered on multiple occasions, including several missed shifts in March 2025. The resident had a history of significant medical conditions, including a traumatic spinal fracture, subdural hemorrhage, and lower extremity impairment, resulting in total dependence for activities of daily living and mobility. The care plan and physician orders required regular monitoring of urine output due to the presence of a Foley catheter and recent UTIs, but this was not consistently performed or recorded. Record reviews showed that the resident experienced recurrent UTIs, as indicated by laboratory results showing cloudy urine and elevated white blood cell counts. Interviews with nursing staff and facility leadership confirmed that urine output monitoring was essential for assessing hydration status and catheter function, and that failure to document output could prevent timely identification of changes in the resident's condition. The facility's policy on changes in resident condition did not address the need for accurate documentation in resident records, contributing to the deficiency.