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Based on record review, policy and procedure review and interviews the Rehabilitation Hospital failed to ensure that one patient, Patient #1, out a total sample of eleven patients, was appropriately assessed on an ongoing basis in accordance with accepted standards of practice and hospital policy regarding urinary catheter care.

The Rehabilitation Hospital's Policy for Indwelling Urinary Catheters, effective 7/1/12, indicated that indwelling urinary catheters are to be removed on day 3 after a catheter is inserted unless there is a physician order to leave the catheter in place with the indication documented by the physician. The Policy indicated the need for a urinary catheter would be assessed daily and the day of admission was day one.

The Physician's Admission History and Physical, dated 7/16/14, indicated that Patient #1 was transferred from an Acute Care Facility to the Rehabilitation Hospital for continued care to increase strength and endurance. The History and Physical indicated that Patient #1 had sustained a fall and fractured his/her right humerus (upper arm bone). The History and Physical indicated that Patient #1 had an indwelling urinary catheter upon admission. The History and Physical indicated that Patient
#1 complained of dysuria (painful urination).

The Nursing Admission Systems Review, dated 12:18 P.M. on 7/16/14, indicated that Patient #1 was admitted to the Rehabilitation Hospital with a urinary catheter in place which was draining clear yellow urine.

The Admission Physician Order Form, dated 9:00 P.M. on 7/16/14, indicated a routine urinalysis was ordered.

The Urinalysis Report, dated 7/17/14, did not indicate that Patient #1 had a urinary tract infection (no white cells, no bacteria present in urine, Patient #1 was afebrile-no fever).

The Physician Progress Note, dated 7/17/14, did not indicate a continued need for an indwelling urinary catheter.

The Physician Order sheet, dated 7/17/14, did not indicate an order for an indwelling urinary catheter.

The 24 Hour Nursing Documentation Flowsheet, dated 7/17/14, indicated that Patient #1 had a urinary catheter draining clear yellow urine. The Nursing Flowsheet did not indicate the symptoms or need for continued use of the indwelling urinary catheter.

The Physician Progress Note, dated 7/18/14, indicated that Patiernt #1 had an indwelling urinary catheter for "retention" (inability to empty bladder completely).

The Physician Order Sheet, dated 7/18/14, did not indicate an order for an indwelling urinary catheter.

The 24 Hour Nursing Documentation Flowsheet, dated 7/18/14, indicated that Patient #1 had a urinary catheter draining clear yellow urine. The Nursing Flowsheet did not indicate the symptoms or need for continued use of the indwelling urinary catheter.

The Physician Progress Note, dated 7/19/14, did not indicate a continued need for an indwelling urinary catheter.

The Physician Order Sheet, dated 7/19/14, did not indicate an order for an indwelling urinary catheter.

The 24 Hour Nursing Documentation Flowsheet, dated 7/19/14, indicated that Patient #1 had a urinary catheter draining "darkened" urine (abnormal urine color may be caused by infection, disease, bleeding, medicines or foods). The Nursing Flowsheet did not indicate the symptoms or need for continued use of the indwelling urinary catheter.

Record Review did not indicate a Physician Progress Note for 7/20/14.

The Physician's Order Sheet, dated 7/20/14, did not indicate an order for an indwelling urinary catheter.

The 24 Hour Nursing Documentation Flowsheet, dated 7/20/14, indicated that Patient #1 had a urinary catheter draining darkened urine. The Nursing Flowsheet did not indicate the symptoms or need for continued use of the indwelling urinary catheter.

The Physician Progress Note, dated 7/21/14, indicated that Patient #1 had dark urine and a urinalysis was ordered.

The Physician Order Sheet, dated 4:45 P.M. on 7/21/14, indicated an order for a urinalysis with culture and sensitivity (C & S-determines the type of bacteria present if there is an infection as well as the appropriate antibiotics for treatment).

The 24 Hour Nursing Documentation Flowsheet, dated 7/21/14, indicated that Patient #1 had a urinary catheter draining urine with "sediment" (possible causes include liver disease, bladder stones or urinary tract infections). The Nursing Flowsheet did not indicate the symptoms or need for continued use of the indwelling urinary catheter.

The Physician Progress Note, dated 7/22/14, did not indicate a continued need for an indwelling urinary catheter.

The Physician Order Sheet, dated 7/22/14, did not indicate an order for an indwelling urinary catheter.

The 24 Hour Nursing Documentation Flowsheet, dated 7/22/14, indicated Patient #1 had a urinary catheter draining cloudy urine with sediment. The Nursing Flowsheet did not indicate the symptoms or need for continued use of the indwelling urinary catheter.

The Urinalysis Report, dated 7/22/14, indicated that the urinalysis ordered on 7/21/14 at 4:45 P.M. was not collected until 7/22/14 at 4:20 A.M. and was not received at the laboratory until 8:16 A.M. on 7/22/14. The Urinalysis Report indicated that Patient #1's urine contained many white cells and bacteria as well as a greater than 100,000 colonies/milliliter presence of the organism Escherichia Coli (indicates a urinary tract infection caused by the bacteria E. coli).

The Vital Sign Graphic Sheet, dated 8:00 A.M. on 7/23/14, indicated that Patient #1 had a temperature of 100.2 (normal 97 to 99-can increase with infection) Fahrenheit (F) and a heart rate of 106 (normal 60 to 100 beats per minute-can increase with infection).

The Physician Progress Note, dated 2:15 P.M. on 7/23/14, indicated that Patient #1 would be started on oral antibiotics for the urinary tract infection.

The Physician Order Sheet, dated 3:00 P.M. on 7/23/14, indicated an order for Cipro (antibiotic) 250 milligrams (mg) by mouth twice a day. The Physician Order Sheet did not indicate an order for an indwelling urinary catheter.

The 24 Hour Nursing Documentation Flowsheet, dated 7/23/14, indicated that Patient #1 had a urinary catheter draining amber urine with sediment. The Nursing Flowsheet did not indicate the symptoms or need for continued use of the indwelling urinary catheter.

The Vital Sign Graphic Sheet, dated 4:00 A.M. on 7/24/14, indicated that Patient #1 had a temperature of 99.8 F, heart rate of 110 and a blood pressure of 106/68 (normal range 90-120 over 60-80).

The 24 Hour Nursing Documentation Flowsheet, dated 11:25 A.M. on 7/24/14, indicated that Patient #1's temperature was 99.2 F, heart rate of 121 and a blood pressure of 70/30. The Nursing Flowsheet indicated that a blood pressure recheck was 68/30 and the Physician was aware.

The Physician Progress Note, dated 7/23/14, indicated that there was a concern for urosepsis (a severe illness that occurs when an infection starts in the urinary tract and spreads into the bloodstream) and Patient #1 would be transferred to an Acute Care Hospital.

The Acute Care Hospital Discharge Summary, dated 8/6/14, indicated that Patient #1's condition continued to decline over the course of his/her admission and he/she was made Comfort Measures Only (CMO). The Discharge Summary indicated that Patient #1 passed away at 6:00 P.M. on 8/6/14 from acute respiratory failure and sepsis (a life-threatening complication of an infection).