Failure to Follow Care Plan for Catheter Privacy Bag
Penalty
Summary
Facility staff failed to follow the comprehensive care plan for a resident with an indwelling Foley catheter by not maintaining a catheter privacy bag as care-planned. The resident had diagnoses including uropathy and an order for a 16 French Foley catheter with a 10 cc balloon due to obstructive and reflux uropathy. On the most recent MDS quarterly assessment, the resident was coded as having an indwelling catheter and scored 15/15 on the BIMS, indicating cognitive intactness for daily decision-making. The comprehensive care plan, initiated on 05/05/2025 and revised on 09/08/2025, identified a catheter focus and included an intervention to maintain a catheter privacy bag. During an observation from the facility hallway on 02/03/2026 at approximately 2:40 p.m., the resident’s catheter collection bag, containing urine, was seen hanging on the hallway side of the bed without a privacy bag in place. In a subsequent interview on 02/04/2026, the unit manager LPN stated that the purpose of a comprehensive care plan is to provide instructions for a resident’s care and, after reviewing the resident’s care plan, acknowledged that the intervention to maintain a catheter privacy bag was not being followed. Administrative staff, including the administrator, DON, regional director of clinical services, and assistant DON, were informed of these findings on 02/05/2026, and no additional information was provided before survey exit.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.