Failure to Follow Physician Orders and Monitor Urinary Retention
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary care and services related to urinary retention and bladder management for one resident. The facility’s policies required licensed nurses to document and implement physician orders and outlined expectations for bowel and bladder retraining, including assessment of continence status and voiding patterns. For this resident, the January care plan did not include a problem for urinary retention. A physician’s order dated mid-January directed staff to check post-void residual (PVR) every six hours for three days, to perform an in-and-out (I/O) catheterization if the PVR was greater than 250 cc, and to notify the physician if there were two or more consecutive catheterizations every six hours for three days. On a specific date in January at 1200 hours, the Medication Administration Record documented a PVR of 337 cc, which exceeded the ordered threshold for I/O catheterization. There was no documentation in the progress notes or closed medical record that an I/O catheterization was performed in response to this elevated PVR, that the physician was notified of the continued urine retention, or that the resident was reassessed or further monitored after the 337 cc residual was identified. The 337 cc PVR entry was the last documented PVR in the ordered sequence. During interview and concurrent record review, an RN confirmed that if a resident continued to retain urine after three days, the physician should be notified, reassessment and monitoring should occur, and a care plan problem should be created, and verified that these steps were not documented for this resident. These failures had the potential to negatively impact the resident’s well-being.
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.