Failure to Honor Resident's Catheter Care Preferences and Self-Determination
Penalty
Summary
The facility failed to honor a resident's right to self-determination by not accommodating the resident's repeated requests to have their urinary catheter bag changed from a leg bag to a bedside gravity drainage bag at night. Despite being alert, oriented, and able to communicate needs, the resident was left with a leg bag overnight, resulting in urinary leakage, a saturated bed, and significant distress. The care plan did not address the resident's new supra pubic catheter or specify the resident's preferences for catheter care, such as the use of different collection bags during the day and night. Additionally, the physician's orders did not specify the type of collection bag to be used at different times, and there was no documentation that the catheter and collection bag had been changed as ordered for the month. Interviews with nursing staff confirmed that the resident had requested the change to a bedside bag weeks prior, but the request was not fulfilled. Observations showed the resident was visibly upset and that no bedside gravity drainage bag was present in the room. Both LPNs and facility leadership acknowledged that residents with urinary catheters should have their collection bags changed to a bedside bag when lying down, and that the resident's rights and requests should have been honored. The failure to address the resident's needs led to loss of dignity and mental anguish for the resident.