F0550

D

Failure to Maintain Dignity for Residents With Foley Catheters

Rockville, Maryland Survey Completed on 01-14-2026

Penalty

No penalty information released

Summary

Facility staff failed to honor residents’ rights to dignity and self-determination by not placing urinary catheter drainage bags in privacy/dignity bags as ordered and expected. During a complaint survey on 1/13/26 at 12:25 PM, Resident #14 was observed lying in bed with a Foley catheter drainage bag hanging off the left side of the bed frame, and the bag was not placed in a privacy/dignity bag to enhance the resident’s privacy. Review of Resident #14’s January 2026 Treatment Administration Record showed a physician’s order, written on 1/11/26, for catheter care specifying that a dignity Foley bag was to be in use every shift.

At 12:27 PM on the same date, Resident #15 was observed lying in bed with a Foley catheter drainage bag hanging off the side of the bed, also not placed in a dignity bag. When informed of these findings at 12:35 PM, RN #15 acknowledged that the drainage bags should have been in privacy bags. These observations demonstrated that staff did not consistently follow physician orders or facility practice to maintain resident dignity for 2 of 5 residents reviewed for urinary catheters during the complaint survey.