Inaccurate I&O Documentation for Resident With Indwelling Catheter
Penalty
Summary
Facility staff failed to accurately document intake and output (I&O) for a resident admitted with an indwelling urinary catheter. The resident had a diagnosis of urinary retention and, per the History and Physical, did not have the capacity to understand and make decisions, with fluctuating capacity. The Minimum Data Set indicated the resident required supervision with toilet hygiene. The resident’s care plan, dated 1/7/2026, identified the presence of an indwelling urinary catheter due to urinary retention, with a goal for the resident to remain free from catheter-related trauma and show no signs or symptoms of urinary tract infection. The care plan interventions included monitoring and documenting I&Os and monitoring for signs and symptoms of discomfort and frequency of urination. Record review of the Medication Administration Record from 1/3/2026 showed that, for multiple consecutive days and shifts, the resident’s I&O was documented only as “x2” rather than in measured amounts. Specifically, from 1/4/2026 to 1/16/2026, day and evening shifts documented I&O as “x2,” and night shifts documented “x2” from 1/4/2026 to 1/8/2026 and 1/10/2026 to 1/16/2026. In interviews, an RN stated that documenting urine output as “x2” was not an appropriate way to measure urine output for a resident with an indwelling catheter, explaining that the urinary bag should be emptied, measured, and recorded. The DON stated that CNAs empty the urinary bags and report the amount to the licensed nurse, and that licensed nurses are expected to document the urine output on the MAR in cubic centimeters (cc), not as “x1” or “x2.” The facility’s policy on Intake and Output Documentation, revised 1/2015, required that fluid intake and output be recorded for each resident with an indwelling catheter, with intake and output information recorded at the end of each shift by a licensed nurse.
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