NORMAN, OK – MEDICAL PARK WEST REHABILITATION & SKILLED CARE

Based on record review and interview, it was determined the facility failed to thoroughly assess and monitor the urinary system for one (#1) of four sampled residents who were reviewed for the use of an indwelling catheter.

Resident #1 had received an IV antibiotic from [DATE] through [DATE] for a UTI. An assessment of the resident’s urine was not documented from [DATE] through [DATE]. The resident was admitted to the hospital on [DATE] with [DIAGNOSES REDACTED]. The resident expired on [DATE] with the cause of death septic shock,[MEDICAL CONDITION], urinary tract infection and acidosis.

There was no documentation in the clinical record related to an assessment of the resident’s urine from the time of the first attempt to change the indwelling catheter on [DATE] until the resident was transported to the hospital on [DATE] (a period of 17 days during which the resident had received an IV antibiotic for a UTI from [DATE] through [DATE]).

The DON was asked what the assessment of the resident’s urine consisted of after [DATE]. He stated they did not have an assessment of the urine documented in the nurses notes after [DATE]. He was asked if they had an assessment documented in any other location in the clinical record. He stated he did not see anything else. He stated, That’s the bad thing when you chart by exception.

The DON was asked if the resident’s urine had been assessed in the ER on [DATE] to be dark and purulent would the urine have been dark and purulent when she had been transferred from the facility on [DATE]. He stated yes. He was asked if the nurse had documented an assessment of the resident’s urine on [DATE] before she was transferred to the hospital. He stated no.