Failure to Document Urostomy and Pelvic Drain Output as Ordered
Penalty
Summary
A deficiency was identified when staff failed to document the output from a resident's urostomy and pelvic drains as ordered. The resident, who had a history of bladder cancer, recent urinary tract and pelvic infections, a urostomy, and pelvic drain, was admitted with physician orders and care plans specifying that the amounts drained from both the urostomy and pelvic drains should be recorded. However, review of the Treatment Administration Record (TAR) for August showed multiple instances where documentation of the amounts drained was missing for both the urostomy and pelvic drains. During an interview, an LPN confirmed that Certified Nursing Assistants (CNAs) may have emptied the urostomy without informing the nurse, resulting in the amounts not being recorded. These findings were confirmed during the exit conference with facility leadership.