Bellefontaine Healthcare: Urine Output Records Falsified - CA
The documentation failures at Bellefontaine Healthcare Center left staff unable to accurately track whether Resident 1 was producing adequate urine output, a critical measurement for patients with indwelling catheters who face elevated risks of infection and blockages.
CNA 1 admitted during a September 9 interview that she had no explanation for omitting precise urine measurements on August 15. Her task log for that date showed incomplete documentation, while the official medical record contained different numbers entirely.
The discrepancies emerged during a complaint investigation that revealed systematic problems with how nursing staff monitored and recorded urine output. Licensed vocational nurse LVN 2, who worked evening shifts on August 15 and 17, explained that accurate documentation in milliliters was essential for knowing when to alert physicians about concerning changes.
But the facility's own staff confirmed the numbers didn't match. During a concurrent interview and record review, CNA 1 acknowledged that licensed staff entries in Resident 1's medication administration record were "not consistent with the numbers / amount of urine output documented in Resident 1's urine output task log."
The documentation covered a five-day period from August 15 to August 19, with task logs and official medical records showing different measurements throughout.
LVN 3 described the proper protocol during a 4:50 PM interview: charge nurses were responsible for documenting total urine output in the medical record, while CNAs maintained separate task logs. At shift's end, charge nurses should communicate with CNAs to determine the complete urine output total.
"The urine output entered in the MAR should be the total amount on that shift including the amount in the CNAs urine output task log and should be documented in ml and not how many times the resident urinated," LVN 3 stated.
The nurse emphasized that accurate measurements were crucial for assessing whether Resident 1 maintained adequate urine output and proper hydration status.
Director of Nursing confirmed the communication breakdown during a 5:13 PM interview. She stated CNAs should have communicated actual urine volumes to charge nurses, who should have documented measurements in milliliters rather than urination frequency.
The DON acknowledged this documentation was necessary "to accurately monitor any changes in the resident's urine output and get assessed for signs of dehydration."
For patients with indwelling catheters like Resident 1, precise urine measurement serves as an early warning system. Sudden decreases can signal kidney problems, dehydration, or catheter blockages from blood clots or other materials that prevent urine from flowing properly.
The facility's own policy, revised in July 2017, required that "all services provided to the resident shall be documented in the resident's medical record." The policy specified that documentation should "facilitate communication between the Inter Disciplinary Team regarding the resident's condition and response to care."
Most critically, the policy mandated that medical record documentation be "objective, complete, and accurate."
The inspection found the facility failed to meet these basic standards. Instead of the clear communication chain outlined in policy, CNAs and licensed nurses maintained separate, inconsistent records that obscured Resident 1's actual condition.
When urine output documentation fails, medical staff lose their ability to detect early signs of serious complications. Dehydration in elderly residents can progress rapidly, while catheter blockages can cause dangerous backup of urine into the kidneys.
The investigation revealed that multiple staff members understood the proper procedures but failed to implement them consistently. LVN 2 knew measurements should be documented in milliliters for physician notification purposes. LVN 3 understood that charge nurses needed complete shift totals. The Director of Nursing recognized the importance of accurate monitoring for dehydration assessment.
Yet despite this knowledge across all levels of nursing staff, Resident 1's urine output records remained incomplete and contradictory for nearly a week.
The documentation failures meant that physicians reviewing Resident 1's medical record would see inaccurate information about kidney function and hydration status. Without reliable baseline measurements, detecting concerning changes becomes nearly impossible.
CNA 1's inability to explain her incomplete documentation on August 15 highlighted the casual approach to what should be precise medical monitoring. Her admission that she "did not remember why she did not put an exact amount of urine emptied" suggested the omission wasn't an isolated oversight but part of a pattern of inadequate attention to critical measurements.
The case illustrates how communication breakdowns between nursing assistants and licensed staff can compromise patient safety, leaving vulnerable residents like those with catheters without the careful monitoring their conditions require.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Bellefontaine Healthcare Center from 2025-09-09 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 21, 2026 · Our methodology
THE BELLEFONTAINE HEALTHCARE CENTER in PASADENA, CA was cited for violations during a health inspection on September 9, 2025.
CNA 1 admitted during a September 9 interview that she had no explanation for omitting precise urine measurements on August 15.
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.