Failure to Document Suprapubic Catheter Output as Ordered
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident with a suprapubic catheter, as required by accepted professional standards and physician orders. Specifically, the urine output for the resident was not documented for four consecutive days, despite clear orders to check and record catheter output every shift. The resident's care plan and physician orders both specified the need for regular monitoring and documentation of urine output, but review of the Medication Administration Record (MAR) and progress notes confirmed the absence of this documentation for the specified period. Interviews with the Assistant Director of Nursing (ADON), Director of Nursing (DON), and a CNA revealed that staff were aware of the documentation requirements but could not explain the lack of entries for those days. The resident involved had a history of neuromuscular dysfunction of the bladder, chronic heart failure, and type 2 diabetes, and required substantial assistance with activities of daily living. She had a suprapubic catheter and colostomy bag due to incontinence, and her care plan included specific interventions for catheter care and monitoring. Despite in-service training on catheter changes and PPE, there was no evidence that staff were trained on the importance of documenting urine output. The DON confirmed that no documentation could be found for the missing days and acknowledged the facility followed the Lippincott Manual of Nursing Practice for catheter care procedures.