HospitalInspections.org

Based on record review and interview facility staff failed to ensure Intake and Output is measured as per physician orders in 1 of 5 medical records reviewed for Intake and Output (Patient (Pt) #1), failed to complete indwelling catheter care (Foley) assessments and interventions in 2 of 2 medical records reviewed for Foley care (Pt #1, #2); and failed to reassess and evaluate pain management needs for effectiveness in 3 of 10 medical records reviewed for pain assessments (Patient (Pt #1, #2, #3), in a total sample of 10 medical records reviewed.

Findings Include:

Review of policy and procedure #17507191 titled, "Hospital Based Assessment & Documentation Policy" last revised 02/02/2025 revealed the following:
- "Data collection/Reassessment is designed to evaluate the patient's response to care and interventions and to determine if a change to the plan of care is warranted."
- "Additional data collection/reassessments are done when the patient's diagnosis/condition warrants."
- "All entries are automatically timed and dated. Information should be entered following acquisition of data or when care is given."
- "Each discipline documents their interventions and the patient's response to these interventions in the patient's health care record."

Review of policy and procedure #16559148 titled, "Indwelling Urinary Catheter (Foley)" last reviewed 01/08/2025 revealed the following:
- "Catheter care must be performed on a minimum of a daily basis. Care will also be completed as needed..."

Review of policy and procedure #13867165 titled, "Pain Management Resource" last revised 06/21/2023 revealed the following:
- "Assess the patient to identify the potential source of pain and implement appropriate non-pharmacological and/or pharmacological interventions."
- "Reassess following interventions..."
- "Parental route (intravenous)-within 1 hour or as needed based on individual patient need and clinical condition."
- "Enteral route (oral)-within 2 hours or as needed..."
- "Reassessment includes pain intensity/score, adverse effects, and sedation (for patients receiving opioid analgesics)."

Pt #1:

Review of Pt #1's medical record revealed Pt #1 was admitted to the inpatient unit on 10/12/2024 at 9:48 AM with a diagnosis of Sepsis (infection of the blood stream) with Acute Renal Failure, Acute Kidney Injury, Metabolic Acidosis (too much acid in the body), and Generalized weakness; Pt #1 was discharged on 10/30/2025 at 9:15 AM.

Review of Urology F's physician progress note dated 10/12/2024 at 4:06 PM revealed, "Patient is a 75 y.o. (year old)...presents with h/o (history of) prostate cancer and obstructive uropathy (structural/functional issue with normal urine flow)...Pt has complicated GU (genitourinary) (reproductive and urinary systems) h/o s/p (status post) xrt (radiation treatment) for...prostate cancer."

Review of Pt #1's physician orders dated 10/12/2025 at 9:53 AM revealed orders for Intake and Output to be measured "Every Shift" (the order was discontinued at discharge).

Intake/Output:

Review of Pt #1's Intake flowsheet from 10/12/2025 through 10/19/2025 revealed there was no documentation of breakfast, lunch, and dinner intake on 10/13/2025, 10/14/2025, 10/15/2025. There was no documentation of breakfast and lunch intake on 10/16/2025, no documentation of lunch intake on 10/17/2025, and no documentation of dinner intake on 10/18/2025.

Review of Pt #1's Urine Output/Assessment flowsheets from 10/12/2025 through 10/19/2025 revealed there was no documentation of staff measuring urine output on 10/12/2025, 10/13/2025, 10/14/2025, 10/15/2025, 10/16/2025, 10/17/2025, 10/18/2025 and 10/19/2025.

Genitourinary nursing assessments/Foley care interventions:

Review of Pt #1's GU nursing assessment flowsheet from 10/12/2025 through 10/19/2025 revealed the nursing assessments did not address Pt #1's symptoms of urinary retention.

Review of Pt #1's GU flowsheet revealed on 10/13/2025 at 11:45 AM "Foley Catheter" was documented under GU interventions. Review of the nursing assessment flowsheets from 10/13/2025 through 10/19/2025 revealed there was no documentation of staff performing daily catheter care interventions as per policy.

Pain assessments:

Review of Pt #1's pain medications revealed orders dated 10/13/2025 at 11:41 AM for Oxycodone 10 milligrams (mg) by mouth every 4 hours as needed and Morphine 2 mg intravenous every 4 hours as needed.

Review of Pt #1's Medication Administration Record (MAR) and nursing pain assessments revealed the following:
-On 10/13/2025 Pt #1 was given Oxycodone for a pain level 6 out of 10 (moderate pain) at 2:18 PM, nursing staff did not complete a pain reassessment until 5:50 PM (3 hours and 44 minutes later); should be within 2 hours for oral medication as per policy.
-On 10/18/2025 Pt #1 was given Morphine for a pain level of 8 out of 10 (severe pain) at 7:00 PM, nursing staff did not complete a pain reassessment until 10:06 PM (3 hours and 6 minutes later); should be within 1 hour for intravenous medication as per policy.
-On 10/19/2025 Pt #1 was given Morphine for a pain level of 7 out of 10 (severe pain) at 2:26 AM, nursing staff did not complete a pain reassessment until 7:01 AM (4 hours and 35 minutes later); should be within 1 hour for intravenous medication as per policy.
-On 10/19/2025 Pt #1 was given Oxycodone for a pain level of 5 out 10 (moderate) at 1:56 PM, nursing staff did not complete a pain reassessment until 9:10 PM (7 hours and 14 minutes later); should be within 2 hours for intravenous medication as per policy.

Pt #2:

Pain assessments:

Review of Pt #2's medical record revealed Pt #2 was admitted on 02/03/2025 at 3:57 PM for a prostate biopsy; Pt #2 was discharged on 02/05/2025 at 12:01 PM.

Review of Pt #2's pain medications revealed orders dated 02/03/2025 at 11:57 AM for Oxycodone 10 milligrams (mg) by mouth every 4 hours as needed.

Review of Pt #2's Medication Administration Record (MAR) and nursing pain assessments revealed the following:
-On 02/03/2025 Pt #2 was given Oxycodone for a pain level 8 out of 10 (severe pain) at 10:59 PM, nursing staff did not complete a pain reassessment until 3:30 AM (4 hours and 31 minutes later); should be within 2 hours for oral medication as per policy.

Pt #3:

Review of Pt #3's medical record revealed Pt #3 was admitted on 02/02/2025 at 4:28 PM with urinary retention and blood in urine with a concern for metastatic cancer; Pt #3 was an inpatient at the time of review.

Foley care interventions:

Review of Pt #3's nursing flowsheets revealed a Foley catheter was placed on 02/02/2025 at 10:30 PM, there was no documentation of staff performing daily catheter cares on 02/03/2025 and 02/04/2025.

Pain assessments:

Review of Pt #3's pain medications revealed orders dated 02/02/2025 at 5:02 PM for Morphine 2 mg intravenous every 4 hours as needed.

Review of Pt #3's Medication Administration Record (MAR) and nursing pain assessments revealed the following:
-On 02/03/2025 at 2:47 PM Pt #3's pain level was a 4 out of 10 (moderate), "Medication" was documented as an intervention on the Pain Assessment flowsheets, but Morphine was not given until 4:42 PM (1 hour and 55 minutes later). Nursing staff did not complete a pain reassessment until 6:42 PM (2 hours later) at which time Pt #3's pain level was 7 out of 10 (severe pain).
-On 02/04/2025 at 1:15 AM, Pt #3 was given Morphine for a pain level of 8 out 10 (severe), nursing staff did not complete a pain reassessment until 4:50 AM (3 hours and 5 minutes later).

Per interview with Director of Nursing (DON) B and Nursing Manager C, while reviewing medical records beginning on 02/04/2025 at 12:55 PM, DON B and Manager C confirmed the findings and stated that staff should measure intake and output every shift and document the amounts including breakfast, lunch, and dinner on the Intake and Output flowsheets. DON B and Manager C stated that Foley catheter care should be completed at least daily as per policy and documented under the indwelling catheter flowsheet. Per DON B, staff should be completing the pain reassessments as per policy.