Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that clinical records for a resident with an indwelling urinary catheter were complete and accurate. Specifically, there were multiple instances where intake and output (I&O) documentation was missing from the Treatment Administration Records (TAR) on several scheduled dates, despite active physician orders requiring I&O to be recorded twice daily. The Regional Quality Improvement Specialist confirmed that I&O should be documented on the TAR by nursing staff, including information provided by CNAs, as the provider reviews the TAR for urinary output. Additionally, a nursing progress note regarding the resident's catheter care was entered several days after the event occurred, without being marked as a late entry. The note described the removal and reinsertion of a catheter due to the resident's complaint of urinary discomfort and lack of urine drainage, but was not documented until five days later. Furthermore, there was no evidence of a provider order for the catheter insertion on the date it was performed, although the nurse stated a verbal order had been received but not entered. These documentation lapses resulted in incomplete and inaccurate clinical records for the resident.