F0550

D

Failure to Maintain Resident Dignity for Catheter Care and Privacy During Personal Care

Windom, Minnesota Survey Completed on 01-27-2026

Penalty

No penalty information released

Summary

The deficiency involves failure to maintain resident dignity related to catheter management and privacy during personal care for two residents. One resident with Alzheimer's disease and dementia, who had a urinary catheter placed by hospice on 1/2/26, was observed on two separate occasions with the catheter collection bag exposed and improperly positioned. On one occasion, the catheter bag was hanging from a garbage can next to the resident's recliner without a dignity cover, despite the resident's care plan identifying self-care deficits and the need for staff assistance. On another occasion, the same resident was observed in bed with the catheter bag placed on the floor in a wash basin, again without a dignity cover, even though a dignity bag was available in the closet. Staff, including an RN and an LPN, acknowledged that urine collection bags should be covered for dignity and should not be hung from garbage cans.

The second resident, who had anxiety disorder and required two staff for bed mobility, was left without adequate privacy during care. During morning care, a nursing assistant exited the resident's room without shutting the door, leaving the resident sitting on the edge of the bed wearing only a brief secured at the waist with pants pulled down to the knees, while two other nursing assistants supported the resident in a seated position. The resident was yelling for help while the door remained open and the privacy curtain was not drawn. Staff later stated that the door should have been shut during this care. The DON reported that she expected doors to be shut during cares and that catheter bags should have covers, and the facility's Resident Dignity policy directed staff to maintain the dignity of every resident.