Failure to Implement Physiatrist’s Urinary Monitoring Recommendations
Penalty
Summary
The deficiency involves the facility’s failure to follow a physiatrist’s recommendations for monitoring a resident’s urinary status. The resident, identified as CL2, was admitted with COVID, shingles, a recent fall requiring rehab, bowel and bladder incontinence, altered mental status, encephalopathy, and BPH. A Physical Medicine and Rehab note documented that, as part of the assessment and plan for BPH, the physiatrist recommended monitoring urine output and post-void residuals (PVRs). However, a review of the resident’s physician orders did not show any orders for urine output or PVR monitoring. During an interview, the DON stated that nursing staff were not aware of the physiatrist’s recommendations and, as a result, these recommendations were not communicated to the primary physician. The DON confirmed that the recommendations for urine output and PVR monitoring were not implemented. The surveyors determined that the facility failed to ensure that the physician’s recommendations for urine and PVR monitoring were followed for this resident, in violation of 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services and 28 Pa. Code 211.5(f) Clinical Records.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.