F0690

D

Failure to Monitor and Document Urinary Output for Catheterized Resident

Kingsford, Michigan Survey Completed on 02-03-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to monitor and document urinary output for a resident with an indwelling urinary catheter. The resident had multiple significant diagnoses, including neurogenic bladder, diabetes, paraplegia, and a Stage 4 sacral pressure ulcer, and was dependent on staff for toileting hygiene, bed mobility, and transfers. The MDS documented the presence of an indwelling urinary catheter, and the MAR/TAR included an order to maintain the Foley catheter and provide care every shift for urinary retention beginning in late October 2025. Despite this, the EMR contained no documented measured amounts of urine output from the catheter over the review period.

From late October through mid-December 2025, CNA point-of-care documentation consistently coded the resident as "3 - Continence not rated due to indwelling catheter" under bladder elimination, with no entries describing catheter patency or the amount and character of urine output. There was also no documentation of measured urine output after the nephrostomy tube was clamped and then removed by urology on 10/27/2025, even though the urology note indicated uncertainty about how much had been draining from the nephrostomy tube and referenced prior sepsis and hydronephrosis. The facility’s own catheter use policy required ongoing monitoring for changes in condition related to potential catheter-associated UTIs, including recognizing, reporting, and addressing such changes, but the record lacked objective urine output measurements.

Progress notes show that the resident had a recent history of UTI requiring six weeks of cefepime and vancomycin, and later developed moderate to severe hematuria. On 12/16/2025, staff documented multiple issues with the catheter, including urine leaking around the catheter, blood mixed with urine, lack of patency, and repeated need for flushing. That afternoon, the resident was found soaked in blood from the catheter insertion site with no urine in the drainage bag, prompting transfer to the ED. Subsequent documentation indicated the resident was hospitalized with heart rhythm issues, UTI treated with antibiotics, and anemia requiring blood transfusions. Interviews with the DON revealed inconsistent statements about whether urinary output for catheterized residents should be measured routinely, and the DON ultimately stated that output was only measured when ordered by a physician, even for residents with a history of UTI and hydronephrosis and recent nephrostomy tube removal. No physician order for urine output measurement was obtained, and no such measurements were documented.