Failure to Maintain Dignity by Leaving Catheter Bag Uncovered and Visible
Penalty
Summary
Surveyors identified a dignity-related deficiency when a resident with an indwelling urinary catheter was repeatedly observed with an uncovered urinary catheter bag visible from the hallway. On three separate observations over consecutive days, the resident was lying in bed with the catheter collection bag hanging from the side of the bed, containing visible urine and lacking any cover, making it observable to anyone passing by. Record review showed the resident had diagnoses including hypertension, osteoarthritis, and obstructive uropathy, and a Quarterly MDS indicated cognitive impairment and the presence of an indwelling urinary catheter. The resident’s care plan, updated prior to the observations, specified that the catheter collection bag should be stored inside a protective dignity pouch, but this intervention was not implemented during the observed times. During an interview, the DON acknowledged that the catheter bag was visible from the hallway and stated that the facility had dignity covers that staff were supposed to use. This failure to follow the care-planned intervention to store the catheter collection bag in a protective dignity pouch resulted in the resident’s urinary catheter bag being exposed and visible from the hallway on multiple occasions.
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