Ridgeview Skilled Nursing Facility admitted the patient in September with a fractured sacrum and neuromuscular dysfunction of the bladder. The facility's care plan specifically required staff to "observe and document intake and output as per the facility policy."
But when federal inspectors asked to see those records on November 25, the Director of Nursing said she had no access to the patient's clinical record. The facility couldn't provide any intake and urine output documentation.
The nursing director explained it was past the 30-day period from when the patient was admitted and discharged. No monitoring records existed anywhere.
Licensed Nurse 1 told inspectors the care plan was in place. During each shift, certified nursing assistants were supposed to empty the patient's urinary bag, record the output, and inform charge nurses of the total at shift's end.
The system appeared to function on paper. CNA 1 confirmed the process during interviews, stating that after emptying the urinary bag, "the urine output was being recorded and would inform the charge nurse of the total urine output at the end of their shift."
Yet no documentation existed to prove any of this monitoring actually occurred.
The patient's medical condition made urine monitoring critical. Neuromuscular dysfunction of the bladder affects normal bladder control and function. Combined with a sacrum fracture at the base of the spine, the patient required careful observation of urinary output to prevent serious complications.
The facility's own policy, dated November 21, emphasized the importance of following care plans: "The facility shall implement each patient's care plan according to patients' needs."
When inspectors returned for a follow-up interview on December 1, the nursing director acknowledged that "a care plan was important to know the plan of care for Resident 1 and follow the interventions listed."
The admission occurred during a period when the patient was particularly vulnerable. The combination of spinal injury and bladder dysfunction created risks that required consistent monitoring. Low urine output in patients with catheters can signal blockages, infections, or kidney problems.
Federal inspectors classified the violation as having "minimal harm or potential for actual harm" affecting "few" residents. But the failure represented a complete breakdown in a basic nursing function.
The missing documentation left no way to verify whether staff had detected problems early, whether the patient received adequate fluids, or whether medical interventions were needed during the stay.
Staff interviews revealed a disconnect between stated procedures and actual practice. While nurses and aides described the monitoring process in detail, no records supported their accounts.
The facility's care plan system appeared designed correctly. The September 15 care plan for catheter management included specific interventions for monitoring. Staff understood their responsibilities during interviews.
But the complete absence of documentation suggested either systematic failure to follow the care plan or wholesale loss of critical medical records.
The nursing director's explanation that records disappeared after 30 days raised additional questions about the facility's record-keeping practices. Federal regulations require nursing homes to maintain clinical records for extended periods.
The patient's discharge occurred sometime before the November 24 inspection, but the exact timeline remained unclear from available documentation.
Inspectors found no evidence that intake and output monitoring had occurred at any point during the patient's stay. The violation represented not just missing paperwork, but potentially missed opportunities to identify serious medical complications.
For a patient with bladder dysfunction and a catheter, consistent urine output monitoring serves as an early warning system. Sudden decreases can indicate catheter blockages requiring immediate attention. Gradual declines might signal kidney problems or dehydration.
Without documentation, medical staff had no way to track patterns, identify concerning trends, or make informed treatment decisions.
The facility acknowledged the importance of care plan compliance during follow-up interviews. But the nursing director's admission that records were inaccessible highlighted systemic problems beyond the individual patient's case.
The inspection occurred as part of a complaint investigation, though the specific complaint details were not included in the public report.
Ridgeview Skilled Nursing Facility operates at 9825 Glen Center Drive in San Diego. The November 24 inspection identified the care plan violation as the primary deficiency requiring correction.
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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