Failure to Document Resident Urine Output per Policy and Professional Standards
Penalty
Summary
The facility failed to follow its own policy and procedure regarding charting and documentation in accordance with professional standards of practice for one of three sampled residents. Certified nursing assistants (CNAs) did not consistently document a resident's urine output every shift on several specified dates. This incomplete documentation was identified during a review of the resident's bladder elimination record, which showed missing entries for multiple days. The resident involved had a medical history including cerebral infarction, kidney stones, muscle weakness, and constipation, and was assessed as having moderate cognitive impairment. The facility's expectation, as stated by both a licensed vocational nurse (LVN) and the director of nursing (DON), was that CNAs document each instance of assistance with urination promptly and accurately, not just at the end of the shift. However, the bladder elimination record was found to be incomplete, with some entries missing for the days in question. The facility's policy required that all services provided to residents, including assistance with elimination, be documented in the medical record to ensure communication among the care team and to monitor residents' conditions. The American Nurses Association's professional standards also emphasize the importance of clear, accurate, and complete documentation. The failure to document as required meant that the care provided could not be verified and did not meet the facility's or professional standards for recordkeeping.