Lakewood Healthcare: Catheter Care Documentation Gaps - CA
The resident required monitoring of urinary drainage from their Foley catheter bag for signs and symptoms of infection every shift, along with accurate urine output measurements, starting February 7 at 3 p.m. But nurses skipped documentation for the evening shift on February 7 and the night shift on February 8.
Training Nurse 1 told inspectors that missing documentation meant the care was not provided, which could negatively affect residents' quality of care. The trainer explained that changes in urine color, reduced drainage, or sediment presence could indicate infection requiring immediate attention.
Registered Nurse Supervisor 1 reviewed the resident's medication administration record during the inspection. The supervisor confirmed there was no documentation of urinary drainage assessment or accurate urine output for the two missed shifts.
"It was unclear if Resident 1 had any signs or symptoms of infection," the supervisor told inspectors.
The supervisor emphasized that licensed vocational nurses should document catheter assessments on the medication administration record every shift. She called it standard of care and important for following physician orders.
"The lack of assessment and documentation increased the risk of quality of care," the supervisor stated.
Proper Foley catheter care requires monitoring multiple factors that signal potential problems. The supervisor explained that nurses must observe urine output, color changes, monitor for pain, and follow up with a urologist when needed.
Dark or concentrated urine might indicate a resident needs more fluids. Sediment in the urine could signal a blockage requiring immediate intervention.
The facility's job description for licensed vocational nurses requires providing nursing care as ordered by physicians and recording care information accurately, timely and concisely. The description specifically states that LVNs should complete all required documentation, including resident assessments and interventions, in the medical record.
Lakewood Healthcare's policy on indwelling catheters, dated September 1, 2014, mandates that catheter care includes intake and output recording. The policy requires documentation of catheter care to be maintained in residents' medical records.
Urinary tract infections represent one of the most common complications for nursing home residents with catheters. Without proper monitoring and documentation, infections can progress undetected, leading to serious complications including sepsis.
The inspection occurred following a complaint about care at the facility. State inspectors classified the violation as having minimal harm or potential for actual harm, affecting few residents.
Training Nurse 1's statement that undocumented care equals care not provided reflects a fundamental principle in healthcare: if it's not documented, it didn't happen from a legal and quality assurance perspective.
The supervisor's acknowledgment that missing assessments made it impossible to determine whether the resident showed infection symptoms highlights the direct patient safety implications. Without documented baseline information, nurses on subsequent shifts cannot identify changes that might indicate developing problems.
Foley catheters require careful monitoring because they provide a direct pathway for bacteria to enter the urinary system. Regular assessment of urine characteristics helps detect early signs of infection before symptoms become severe.
The facility's own policies recognized these requirements. The 2014 catheter care policy specifically mandated intake and output recording as part of proper catheter management.
Licensed vocational nurses carry significant responsibility for direct patient care in nursing homes. Their job description at Lakewood Healthcare explicitly required accurate and timely documentation of all nursing interventions and assessments.
The February incident involved fundamental nursing care that should occur routinely every shift. Evening and night shift nurses both failed to complete required documentation, suggesting potential staffing or training issues.
The supervisor's explanation of proper catheter monitoring revealed the complexity of care required. Nurses must evaluate urine output, color, clarity, presence of sediment, and resident comfort levels. They must also recognize when specialist consultation becomes necessary.
Without this documentation, the facility cannot demonstrate that appropriate care was provided. More importantly, subsequent caregivers lack essential information needed to provide safe, effective care.
The resident's catheter care plan began February 7 at 3 p.m., making the immediate documentation failures particularly concerning. Initial monitoring establishes baseline conditions that guide ongoing care decisions.
State inspectors found that nurses at Lakewood Healthcare Center failed to meet basic documentation requirements that protect resident safety and ensure continuity of care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Lakewood Healthcare Center from 2025-08-28 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
LAKEWOOD HEALTHCARE CENTER in DOWNEY, CA was cited for violations during a health inspection on August 28, 2025.
But nurses skipped documentation for the evening shift on February 7 and the night shift on February 8.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.