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F0550
D

Failure to Cover Urinary Catheter Bags Compromises Resident Dignity

Los Angeles, California Survey Completed on 05-16-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain or enhance the dignity and respect of two residents by not ensuring that their urinary catheter bags were covered with privacy (dignity) bags. For one resident, who was admitted with acute kidney failure, encephalopathy, and hypertension, and was cognitively impaired and required extensive assistance with activities of daily living, observations revealed that the urinary catheter bag was hanging from the bed frame without a dignity cover. Both a CNA and a treatment nurse confirmed during interviews that the catheter bag should have been covered to maintain the resident's privacy and dignity, and the DON acknowledged that the lack of a dignity bag could affect the resident's psychosocial wellbeing. For another resident, who had a pressure ulcer, depression, and severely impaired cognition, the care plan specifically indicated that the indwelling Foley catheter should remain in a privacy bag at all times. However, observation showed the catheter bag was full and visible to anyone entering or passing by the room. The resident's CNA, the Director of Staff Development, and the DON all stated in interviews that the catheter bag should have been covered for privacy and dignity. A review of facility policies and in-service training materials confirmed that staff were instructed on the importance of providing privacy and dignity to residents, including the use of dignity bags for catheter care. Despite these policies and training, the facility did not ensure that the dignity bags were in place for the two residents, resulting in a failure to provide care in a manner that maintained or enhanced their dignity and respect.

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