Failure to Document and Monitor Urinary Output for Residents with Indwelling Catheters
Penalty
Summary
The facility failed to ensure that residents with indwelling urinary catheters received appropriate treatment and services to prevent urinary tract infections. For one resident with multiple diagnoses including urinary tract infection, neuromuscular dysfunction of the bladder, acute kidney failure, urinary retention, and chronic kidney disease, there was an order to document fluid intake and urinary output as per facility policy. However, it was found that urinary output was not being tracked or documented in the resident's chart, despite a recent UTI diagnosis following a catheter change that resulted in cloudy urine and fever. The Nurse Manager confirmed that output tracking was not occurring and was not documented in the resident's records. Similarly, another resident with diagnoses of obstructive and reflux uropathy, acute kidney failure, and urinary retention also had an order for an indwelling Foley catheter. Review of the electronic health record revealed no documentation of urinary output for this resident. The lack of documentation and monitoring of urinary output for both residents with indwelling catheters represents a failure to provide appropriate catheter care and to implement interventions necessary to prevent urinary tract infections.