Failure to Implement Care Plan Intervention for Foley Catheter Output Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to implement a care plan intervention for a resident with an indwelling Foley catheter. The resident was admitted with diagnoses including cognitive communication deficit, urinary retention, and obstructive and reflux uropathy, and was documented as having moderate cognitive impairment but able to understand and be understood, without disorganized thinking, acute mental status change, or rejection of care. The resident’s MDS indicated dependence on staff for toileting hygiene, bathing, and personal hygiene, and that the resident and family were active participants in the assessment process. A care plan dated 7/16/2025 for the resident’s indwelling Foley catheter included an intervention for nursing staff to monitor and document the resident’s urine output. Record review of progress notes from 7/2025 through 9/2025 showed no indication that urine output was monitored during that period. The DON confirmed that the care plan intervention to monitor urine output, initiated on 7/16/2025, was not implemented and that the physician was not contacted at that time regarding urine output monitoring. The DON also confirmed that the MARs for 7/2025, 8/2025, and 9/2025 did not show urine output monitoring and that an order to monitor intake and output every shift was not obtained until 10/20/2025, at which point total fluid output monitoring began. The DON stated that standard nursing care for a resident with an indwelling catheter should include measurement and recording of output, and that the failure to implement the care plan intervention from 7/16/2025 until 10/20/2025 placed the resident at increased risk of urinary infection and catheter-related complications. The facility’s policy on comprehensive person-centered care plans indicated that care plans are to describe services furnished to help residents attain or maintain their highest practicable physical well-being.
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