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Based on medical record review, interview, and policy review, nursing staff failed to provide Patient #1 with care in accordance with the patient's needs as it specifically relates to the patient's indwelling urinary catheter and discharge needs.

Findings include:

Telephone interview on 12/13/13 at 10:05am with Staff #1, Clinical Services Director, revealed that urinary catheter care is to be performed once a shift with two shifts scheduled each day.

Review of Nursing Daily Focus Assessment dated 8/17-9/15/12 revealed urinary catheter care was routinely provided only once per day. On 8/21, 8/27, 9/4, and 9/15 there is no documentation to indicate catheter care was performed.

Review of Policy "Catheter (urinary) care" last revision 3/2013, indicated urine is to be checked for unusual appearance with immediate notification to the charge nurse/supervisor in the event of bleeding or signs/symptoms of urinary tract infection.

Review of Nursing Daily Focus Assessment revealed blood was noted in the patient's urine on 8/22-8/23/12, 9/10-9/11/12, and 9/14-9/15/12. There is no documentation to indicate the charge nurse/supervisor was notified of this finding.

Review of Policy "Catheter Associated Urinary Tract Infection Prevention" most recent review dated 2/2013, revealed that nursing will generate a Physician reminder to evaluate a patient's need for an indwelling catheter every seven days for swing bed patients.

Review of the medical record dated 8/17-9/15/12 revealed no documentation to indicate a physician reminder related the patient's need for an indwelling urinary catheter was generated in accordance with the facility's policy.

Review of Nursing Discharge Assessment dated 9/15/12 at 10:35am revealed discharge instructions were provided to a family member with no evidence to indicate care specific to the indwelling urinary catheter was provided.