The resident, admitted with a broken tailbone and neurogenic bladder, required careful monitoring of fluid intake and output every shift according to physician orders dated September 15. But when federal inspectors reviewed the records in November, they found gaps in documentation and a facility that couldn't produce basic intake records.
Family Member 1 told inspectors she visited on September 15 and found her relative without the catheter despite a history of bladder problems. "Resident 1 did not have a foley catheter," she said. She had to request that licensed nurses insert one.
The facility hadn't been performing bladder scans or documenting when the resident urinated, according to the family member. Only after she intervened and the medical doctor was notified did staff insert the catheter.
Licensed Nurse 1 confirmed to inspectors that the resident needed the flexible tube "for Neurogenic Bladder" and that "intake and output should be recorded every shift to ensure bladder function."
Yet the medication records from September tell a different story.
On September 15, the day physician orders required monitoring to begin, no urine output was recorded for any of the three shifts. September 23 was marked "NA." September 24 had only an "x" for the morning shift.
The documented output swung wildly from day to day. September 16 showed 60 milliliters in the morning, then 350 in the evening, then 400 overnight. September 21 recorded 550 milliliters in the morning and 750 in the evening, but only 40 milliliters during the night shift.
Certified Nursing Assistant 1 described the process to inspectors: "We emptied Resident 1's urinary bag, record urine output, and inform the charge nurse of the total urine output at the end of the shift."
But the erratic documentation suggested that process wasn't happening consistently.
When inspectors asked Director of Nursing for intake records on November 25, she said the facility couldn't provide them. The records had "passed the 30-day period since Resident 1 was admitted and discharged" and she "could not access the record."
A week later, on December 1, inspectors interviewed the Director of Nursing again. She acknowledged "it was important to document an accurate intake and output to monitor Resident 1's overall health condition."
She still couldn't provide the intake records.
The resident's mental status assessment from September 19 showed intact cognition with a score of 15, meaning they would have been aware of their care and any problems with their catheter management.
The facility's policy on "Bowel and Bladder Management Process," dated April 9, offered no clear guidance for situations like this, according to inspectors.
For residents with neurogenic bladder, consistent monitoring becomes critical. The condition, caused by nerve damage, prevents normal bladder control and can lead to complications including infections, kidney damage, and autonomic dysreflexia if not properly managed.
The inspection was triggered by a complaint, though the report doesn't specify who filed it or what specific concerns prompted the federal review.
The violation was classified as causing minimal harm with potential for actual harm, affecting few residents. But for the family member who had to advocate for basic catheter care, the failure represented a breakdown in fundamental nursing responsibilities.
Federal inspectors noted that proper catheter care requires not just insertion and maintenance, but systematic tracking of how well the device functions. Without accurate intake and output records, medical staff cannot identify developing problems or adjust treatment.
The resident was discharged before inspectors arrived in late November, leaving behind incomplete records and unanswered questions about whether their bladder condition received appropriate monitoring during their stay.
The facility's inability to produce basic intake documentation more than a month after the resident's departure raised additional concerns about record-keeping practices that extend beyond this single case.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Ridgeview Skilled Nursing Facility from 2025-11-24 including all violations, facility responses, and corrective action plans.
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