Failure to Provide Ordered Urinary Drainage Supplies Resulting in Loss of Dignity
Penalty
Summary
A deficiency occurred when the facility failed to maintain the dignity of a resident who was admitted with diagnoses including cerebral infarction with left-sided hemiplegia and hemiparesis, and chronic kidney disease stage three. The resident was cognitively intact, dependent on staff for all activities of daily living, and had a physician's order for a condom catheter with a drainage bag. Despite this order, the facility did not have any large urinary drainage bags available, only leg bags, which were not suitable for the resident's needs. As a result, the resident was placed in an adult incontinence brief instead of the ordered urinary drainage system. The resident expressed dissatisfaction with wearing the adult incontinence brief, stating it caused discomfort and concern for skin breakdown, and made him feel undignified. Staff interviews confirmed that there was a shortage of appropriate urinary drainage bags, and the central supplier acknowledged being recently made aware of the issue. Observations confirmed the resident was wearing an adult incontinence brief due to the lack of proper supplies, and staff were uncertain about when the correct drainage bags would be available.