Health inspection·December 28, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for one (Resident #1) of 5 residents reviewed for Dignity. The facility failed to treat Resident #1 with dignity and promote enhancement of her quality of life when the resident was not provided a privacy bag for her catheter bag. This failure placed residents at risk of not having their right to a dignified existence maintained and a decline in their quality of life. Findings included: Review of Resident #1's Face Sheet, dated 12/28/2024, reflected the resident was a [AGE] year-old female admitted on [DATE]. The resident was diagnosed with obstructive and reflux uropathy (a blockage in the urinary flow causing the urine to flow back to the kidneys). Review of Resident #1's Quarterly MDS Assessment, dated 11/08/2024, reflected the resident was unable to complete the interview to determine the BIMS score. The Quarterly MDS Assessment indicated the resident had an indwelling catheter (a thin tube inserted to the urinary bladder to collect urine and drain to a drainage bag). Review of Resident #1's Comprehensive Care Plan, dated 10/18/2024, reflected the resident had an indwelling catheter and interventions were provide catheter care every shift and position catheter bag away from entrance room door. Review of Resident #1's Physician Order, dated 8/22/2024, reflected CATHETER CARE EVERY SHIFT. Observation and interview on 12/28/2024 at 8:43 AM revealed Resident #1 was in her bed, awake. Resident #1 had a catheter bag hanging at the railings below her bed. The catheter bag and its content were observed visible upon entrance to the room. The catheter bag contained straw-colored fluid at approximately 150 milliliter. The catheter bag did not have a privacy bag. It was also observed that there was no privacy bag in sight. When asked how long she had the catheter bag, the resident did not reply. When asked if she was aware her catheter bag was exposed, the resident did not reply. Observation on 12/28/2024 at 10:49 AM revealed Resident #1's catheter bag still did not have a privacy bag. The content of the catheter bag was still visible upon entrance to the room. Page 1 of 2 676029 676029 12/28/2024 Westpark Rehabilitation and Living 900 Westpark Way Euless, TX 76040

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation and interview with RN A on 12/28/2024 at 10:53 AM, RN A stated if a resident had a catheter, there should be a privacy bag for the catheter bag so the content would not be visible to other residents or visitors. She said without the privacy bag, the resident might be embarrassed, humiliated, or might feel uncomfortable. She said the catheter bag should be inside a privacy bag whether the resident was inside or outside the room. RN A went inside Resident #1's room and saw the resident's catheter bag was exposed. She said she did not notice the catheter bag was exposed when she did her round. She said she was responsible in making sure the catheter bag had a privacy bag. She said she would get a privacy bag for Resident #1's catheter In an interview with the DON on 12/28/2024 at 11:26 AM, the DON stated the catheter bag should have been placed inside a privacy bag to avoid embarrassment and humiliation. The DON said all the residents had the right for a dignified existence and not having a privacy bag was not one of them. The DON said all the staff, including her, were responsible in ensuring the catheter bag was inside a privacy bag. The DON said the expectation was for the staff to make sure the catheter bag had a privacy bag when the resident was in her bed or in the wheelchair. She concluded that she would continually remind the staff the importance of providing dignity and placing the catheter bag inside a privacy bag through an in-service. In an interview with ADON C on 12/28/2024 at 11:44 AM, ADON C stated all the residents should be treated with dignity. She said providing dignity could be done by knocking at the door before going inside the room, talking to the residents in a courteous way, or pulling the privacy curtain while providing care. She said, for a resident with catheter, there should be privacy bag to maintain the resident's dignity. She said without the privacy bag, the resident might prefer to stay inside the room so that other residents would not see she had a catheter. She said the issue was not if the resident was embarrassed or not, but if the staff were providing them dignity. She said the expectation was for the staff to treat the residents with catheter with dignity by placing the catheter bag inside a privacy bag. She said she would collaborate with the DON to do an in-service about maintaining the residents' dignity and placing the catheter bag inside a privacy bag. In an interview with the Administrator on 12/28/2024 at 12:25 PM, the Administrator said the catheter bag should be inside a privacy bag to provide dignity and prevent any embarrassment. He said the expectation was the staff to provide dignity to all the residents. In an interview with CNA B on 12/28/2024 at 12:44 PM, CNA B stated she emptied Resident #1's catheter bag earlier and she saw the catheter bag was exposed. She said she knew there should be a privacy bag so that the resident would not be embarrassed. She said she should have gotten a privacy bag when she saw the resident's catheter bag was exposed or told the nurse that there was no privacy bag. She said there should be a privacy bag whether the resident was inside the room or outside the room to prevent embarrassment. Record review of the facility's policy, Dignity and Respect Policy/Procedure - Nursing Administration revised 05/2007 revealed POLICY: It is the policy of this facility that all residents be treated with kindness, dignity, and respect. Review of facility policy, Indwelling Urinary Catheter Care, Policy and Procedure revised 01.2022 revealed Policy: It is the policy of this facility that each resident with an indwelling catheter will receive catheter care daily and as needed (PRN) for soiling . Purpose: To promote hygiene, comfort, and decrease the risk of infection for a resident with an indwelling urinary catheter . Procedure . 14. Cover the drainage bag with a privacy bag to maintain dignity. 676029 Page 2 of 2