Failure to Ensure Privacy for Resident with Foley Catheter
Penalty
Summary
A male resident with severe cognitive impairment, legal blindness, and an indwelling urinary catheter was observed walking in the hallway with his Foley catheter bag attached to his right calf, visibly over half full of urine and lacking a privacy cover. The resident was assisted by a CNA, who stated she had not seen a privacy cover for the bag and was unsure who was responsible for ensuring privacy covers were in place. The resident himself was unaware of whether a privacy cover was present due to his blindness and expressed indifference about its use. Record review showed that the resident's care plan and physician orders required the use of a privacy bag for the catheter, and the facility's policy also mandated covering the drainage bag to maintain dignity. Interviews with facility staff, including the CNA, LVN, Operations Manager, and DON, revealed inconsistent understanding and implementation of responsibility for ensuring privacy covers were used. The LVN assigned to the resident acknowledged seeing the resident without a privacy cover and admitted not placing one during his shift, despite having access to privacy bags and having received training on their use. The Operations Manager and DON both affirmed the importance of privacy covers and stated that staff had received training and that supplies were available. However, the observation and staff interviews demonstrated a failure to ensure the resident's personal privacy as required by facility policy and the resident's care plan.