HospitalInspections.org

Based on policy review, medical record review and interview, the facility failed to ensure nursing staff followed policy for documentation of urinary output for 2 of 3 (Patient #1 and #3) sampled patients reviewed.

The findings included:

1. Review of the facility's "Standards of Practice Guidelines for Patient Care Units" policy (revised 11/2021) revealed, "...3. Intake and Output measure and document a total at minimum every shift or as ordered..."

2. Medical record review for Patient #1 revealed an admission date of 12/30/2021 with diagnoses that included Acute Displaced Fracture of the proximal right femur. Patient #1 had surgical repair of the fractured femur on 12/31/2021, and was discharged to a rehabilitation facility on 1/6/2022.

Review of nursing notes beginning 12/30/2021 through 1/6/2022 revealed no urinary output was documented for the following days/shifts:
12/30/2021; 7 PM-7 AM shift;
1/5/2022; 7 AM-7 PM shift.

3. Medical record review for Patient #3 revealed an admission date of 12/30/2021 with diagnoses that included Influenza and exacerbation of Chronic Obstructive Pulmonary Disease (COPD). Patient #3 was discharged from the facility on 1/11/2022.

Review of nursing notes beginning 12/30/2021 through 1/11/2022 revealed no urinary output was documented for the following days/shifts:
12/31/2021; 7 AM-7 PM shift;
12/31/2021; 7 PM-7 AM shift.

In an interview on 1/28/2022 at 10:30 AM, the facility's Vice President of Quality and Risk Management verified output should be documented in the medical record at least every shift.