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Based on document review and interview, the nursing staff failed to ensure a patient's urinary output amount was documented per physician order for 1 of 12 medical records reviewed. (Patient #1); and nursing staff failed to notify physician of urine output that was outside of the parameters per physician orders and/or facility policy for 1 of 12 medical records reviewed. (Patient #1)

Findings include:

1. Facility policy titled "Guidelines and Protocols: Inpatient Rehabilitation Hospitals" Policy Number: RH-NU-114 with issue date of 10/1/23 indicated the following: "POLICY: A. To ensure quality patient care, certain standards of care must be upheld. D. A specific physician order will supersede the minimum frequencies noted below. PROCEDURE: Nutrition and Fluids, Routines/Guidelines: Intake and output (I & O) totaled. Minimum Frequency: Per MD order, total each shift."

2. Review of patient #1's medical record indicated the following:
The patient was admitted on 5/18/24 at 11:49 a.m.

(A.) A physician order dated 5/18/24 at 11:59 a.m. and discontinued on 5/22/24 at 12:30 a.m. indicated to notify the physician of urine output less than 100 milliliters in 4 hours.

(B.) A review of nursing flowsheets for Patient #1 indicated the following urine output: and estimated urine amount:
On 5/19/24 at 4:26 p.m. - urinary occurrence of continent and estimated urine output amount was small.
On 5/19/24 at 6:23 p.m. - urinary occurrence of continent and estimated urine output amount was small.
On 5/19/24 at 7:30 p.m. - urinary occurrence of continent and estimated urine output amount was medium.
On 5/19/24 at 9:55 p.m. - urinary occurrence of continent and estimated urine output amount was medium.

(C.) The medical record lacked documentation of measured urine output in milliliters for Patient #1, therefore was unable to determine if the patient had a urine output of greater than and/or lesser than 100 milliliters with each urinary occurrence.

3. During an interview with A1 (Director of Quality Management ) on 7/19/24 at approximately 2:00 p.m., he/she verified the medical record information for patient #1.

4. During a phone interview with N1 on 7/23/24 at 3:32 p.m., N1 verified that they toileted Patient #1 prior to going on break on 5/19/24 at approximately 9:45 p.m. and did not measure Patient #1's urine.