Failure to Maintain Resident Dignity by Not Covering Catheter Bag
Penalty
Summary
Facility staff failed to maintain the dignity and privacy of a resident with an indwelling catheter by not placing the catheter drainage bag inside a privacy bag, as required by the facility's policy and procedure on 'Quality of Life-Dignity.' The resident, who had diagnoses including metabolic encephalopathy, diabetes mellitus, and a sacral pressure ulcer, was dependent on staff for mobility and required substantial assistance with activities of daily living. During an observation, the resident's catheter drainage bag was found uncovered, and both the Treatment Nurse and Director of Nursing confirmed that a privacy bag was not in use, despite acknowledging its importance for resident dignity and privacy. The facility's policy specifically prohibits practices that compromise resident dignity and directs staff to help residents keep urinary catheter bags covered. The failure to follow this protocol was confirmed through staff interviews and record review, demonstrating a lapse in adhering to established standards designed to protect resident privacy and dignity.
Plan Of Correction
F550: Resident Rights/ Exercise of Rights CORRECTIVE ACTION On 3/4/25, the Treatment Nurse for Resident 16 placed the indwelling catheter drainage bag in a dignity privacy (a discreet cover designed to conceal a urine drainage bag). On dates: 3/4/25 to 3/7/25, the Licensed Staff monitored any changes of condition, particularly behavior changes as it relates to resident 16's dignity, privacy, and comfort. Resident 16 did not have any changes of condition at the time, and all needs were met. OTHER RESIDENTS AFFECTED IDENTIFICATION On 3/21/25, the Treatment Nurses (TN) checked all residents with orders for indwelling catheter to ensure that all have privacy dignity bags. No other residents were affected by this alleged deficient practice. All residents with indwelling/condom catheter orders have privacy dignity bags as of 3/21/25. MEASURES AND SYSTEMIC CHANGES In-service was conducted by DON/Designee to Nursing Staff from 3/21/25 to 3/25/25 regarding placement of privacy dignity bags for all residents with indwelling catheters to ensure that quality of life, care tasks, toileting, and promote dignity and respect. The TNs shall monitor daily placement of privacy dignity bags for all residents with indwelling catheters. On 3/21/25, the DSD/Designee provided education to CNAs to ensure that all residents with urinary catheters shall have a privacy dignity bag in place QS. PERFORMANCE MONITORING The Department Managers, during daily rounds Monday to Friday, shall monitor the placement of privacy dignity bags for residents with indwelling catheters. Any negative findings shall be escalated to the licensed staff for correction and reported during daily stand-up meetings to the DON/Designee. PERFORMANCE MONITORING (CONTINUED) The Administrator/Designee will present the results to the QA Committee for monthly review for the next 3 months and quarterly thereafter or until substantial compliance is achieved.