Lakewood Healthcare Center

During a concurrent interview and record review on 8/28/2025 at 1:25 p.m. with Registered Nurse Supervisor (RNS) 1, Resident 1's MAR for 2/2025 was reviewed.

The MAR indicated that nurses were to assess the urinary drainage from the Foley catheter bag for signs and symptoms of infection and the amount of urine output every shift, starting on 2/7/2025 at 3 p.m. RNS 1 stated there was no documentation of the urinary drainage assessment or accurate urine output on the MAR for the evening shift on 2/7/2025 and the night shift on 2/8/2025. RNS 1 stated it was unclear if Resident 1 had any signs or symptoms of infection. RNS 1 stated the LVN should document on the MAR every shift. RNS 1 stated it was standard of care and important to follow the physician's order. RNS 1 stated the lack of assessment and documentation increased the risk of quality of care. RNS 1 stated the Foley catheter care included monitoring urine output, observing color, monitoring for pain, and following up with a urologist (a medical specialist who diagnoses and treats disorders of the urinary system [kidneys, ureters, bladder, urethra]) if needed. RNS 1 stated dark or concentrated urine might mean the resident needed more fluids. RNS 1 stated sediment in the urine may mean there was a blockage.

During a review of the facility's LVN Job Description, undated, the Job Description indicated, LVN's responsibilities included providing nursing care as ordered by the physician and recording care information accurately, timely and concisely.

The Job Description further indicated LVNs should complete all required documentation, including resident assessments and interventions, in the medical record.

During a review of the facility's policy and procedure (P&P) titled Indwelling Catheter, dated 9/1/2014, the P&P indicated, catheter care included intake and output recording.

The P&P indicated documentation of catheter care would be maintained in the resident's medical record.

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