HospitalInspections.org

Based on review of the clinical record and the facility policy it was determined the nursing staff failed to monitor and document the intake and output; perform assessment of an indwelling Foley catheter and notify physician of decreased urinary out put for 1 of 3 sampled patients
(#1) .

The finding include:

Clinical record review revealed Patient #1 was admitted to the facility on 6/26/10, admitting diagnoses included Renal insufficiency with elevated BUN; CVA right hemiplegia, benign prostatic hypertrophy with Foley catheter. Review of the patient's intake and output record revealed at 5 PM on 7/25/10 the patient had urine output of 200 ml with documented
evidence of urinary incontinence leakage. Further review of the record revealed no subsequent documentation of the patient's urinary output from 7/25/10 5 PM to 7/26/10 at 6:20 PM, discharged to the hospital. Additionally there is no assessment of the Foley catheter or documentation to indicate the physician had been notified on 7/25/10 and 7/26/10 of the patient's decrease urinary output.
Review of the facility's intake and output (I & O) policy revision date 1/22/09 revealed the policy specifies to assess retention and excretion of fluids, output is measured and recorded on the nursing shift assessment on the intake and output section if the patient served has a Foley catheter in place. Nursing monitors if the person served is voiding each shift. Nursing to notify physician if the fluid intake, P. O intake or output is poor and document on the nursing shift assessment.