Failure to Maintain Resident Dignity Due to Delayed Call Light Response and Lack of Privacy for Catheter Bags
Penalty
Summary
The facility failed to maintain resident dignity for two cognitively intact female residents. One resident, who had a fractured hip, malnutrition, and COPD, experienced extended call light response times, with documented waits of up to 1 hour and 28 minutes. During these delays, the resident was unable to access timely assistance, resulting in an episode of incontinence. The resident expressed embarrassment, humiliation, and frustration, and apologized to staff for being a bother. Staff interviews and call light logs confirmed the prolonged response times, and the concern was also documented in a grievance form submitted by the resident's family. Another resident, admitted with a sacral fracture and requiring an indwelling Foley catheter, was observed without a privacy covering on her urine collection bag while moving through the facility. The resident reported feeling embarrassed and humiliated after encountering an acquaintance while her urine bag was visible. Observations confirmed the absence of a privacy bag, and staff interviews acknowledged that all urine collection bags should be covered to promote privacy. The facility's own policy required drainage collection devices to be covered to ensure dignity, but this was not followed in the resident's case.