Failure to Maintain Resident Dignity During Meal Service
Penalty
Summary
During meal service, two residents with indwelling urinary catheters were observed in the main dining room without privacy covers on their urinary collection bags. One resident, who was cognitively impaired and physically dependent on staff, was seated in a Broda chair with his catheter bag visible and one-third full of urine, lacking any privacy cover. Another resident, who was cognitively intact but also physically dependent, had her catheter bag attached to her wheelchair, half full of urine, and similarly without a privacy barrier. Both residents' catheter bags were clearly visible to others in the dining area. Interviews with staff confirmed that all wheelchairs were equipped with bags intended to conceal urinary collection bags, and that staff were expected to use these dignity bags when transferring residents. Facility policies required staff to maintain privacy barriers for urinary catheters and to treat all residents in a dignified manner. Despite these policies and staff expectations, the observed failure to use privacy covers during meal service resulted in a lack of dignity for the affected residents.