Failure to Maintain Resident Dignity During Catheter Care and Meal Assistance
Penalty
Summary
The facility failed to provide care in a manner that maintained resident dignity for two residents. For one resident with a history of depression, neurogenic bladder, and quadriplegia, the clinical record indicated the use of an indwelling urinary catheter. Observation revealed that the resident's catheter drainage bag was left uncovered and hanging on the bed frame, contrary to the facility's catheter care policy, which requires privacy covers to be used at all times. This was confirmed by an LPN, who acknowledged that the lack of a privacy cover did not maintain the resident's dignity. For another resident with diagnoses including high blood pressure, cerebral infarction, and dementia, the clinical record and care plan indicated the resident was totally dependent on staff for self-feeding. During a lunch service, staff placed the resident's meal tray in front of her but did not provide the required assistance, leaving the resident without help to eat. This was confirmed by an LPN, who stated that the resident should have been assisted with lunch at the time the tray was delivered. The Director of Nursing confirmed that the facility failed to ensure care was provided in a manner that maintained the dignity of both residents. The findings were based on review of facility policies, clinical records, direct observation, and staff interviews, and were found to be inconsistent with both federal and state requirements for resident rights and nursing services.
Plan Of Correction
Resident R 3 had a catheter dignity bag placed on their catheter bag and resident R44 was fed their meal that day of survey. All residents with catheters will be reviewed to assure dignity bags are placed on catheter bags and residents with an order for assisted feeding will be reviewed and fed their meals. The Director of Nursing will educate nursing staff on placement of dignity bags on the catheter bags and all residents that are assisted with meals will be fed when their tray is delivered. The Director of Nursing or designee will audit catheter bags for dignity bag placement 3 times a week for 3 weeks, then 3 times a week for 2 weeks and 3 times a week for 1 week. Residents with orders for assistance to be fed will be reviewed and audited during mealtime that assistance was provided weekly times 3 and monthly times 2. Results will be turned into the monthly Quality Assurance meeting.