Failure to Maintain Resident Dignity with Foley Catheter Privacy Measures
Penalty
Summary
A resident with a diagnosis of malignant neoplasm of the prostate and an indwelling Foley catheter was observed on multiple occasions without the catheter drainage bag being covered by a privacy bag, as required by physician orders. The resident was cognitively intact and expressed that staff had not offered a leg bag, which he desired. Observations by surveyors and facility staff confirmed that the Foley catheter drainage bag was not in a privacy bag during ambulation and while the resident was seated in his room. The resident did not have a leg bag, despite physician orders specifying its use when out of bed. Interviews with the Rehab Director, Unit Manager, and DON confirmed that the Foley catheter should have been in a privacy bag and that a leg bag should have been provided for the resident's dignity and mobility. The DON acknowledged that staff failed to change the resident's Foley catheter drainage bag to the facility's specific urinary drainage and privacy bag as ordered. These actions and inactions resulted in a failure to maintain the resident's dignity and comply with physician orders regarding catheter care.