Failure to Implement Care Plan for Catheter Output Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to implement a care plan intervention to document urinary catheter output for a resident with an indwelling catheter. The resident was admitted with diagnoses including overactive bladder and intellectual disabilities, and a Discharge MDS indicated severe cognitive impairment and the presence of an indwelling urinary catheter. The resident’s catheter/ostomy care plan, dated 10/9/25, included an intervention to document urinary output, yet the output record showed only four entries over a nine-day admission, despite the expectation that catheter output be documented at least once per shift. Nursing documentation later noted that the resident’s catheter was not draining, attempts to flush with sterile water were unsuccessful, and the Foley catheter was removed and replaced, after which 500 mL of dark yellow urine with sediment immediately drained. Interviews confirmed that CNAs were expected to empty catheter bags multiple times per day and document the amount under urine output, and the DON confirmed that urinary catheter output should be documented minimally every shift. The DON acknowledged that the resident had only four documented outputs during the entire admission, demonstrating that the care plan intervention to document catheter output was not consistently implemented.
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