Failure to Obtain Physician's Order for Self-Administered Colostomy Care
Summary
The facility failed to obtain a physician's order for a resident to self-perform colostomy care and did not complete a full evaluation to assess the resident's ability to self-administer this care. The resident, who had moderately impaired cognition and an ostomy, was performing colostomy care independently without any documented assessment or physician's order authorizing self-administration. The facility's policy required a physician's order and a documented assessment for self-administration of treatments, which was not followed in this case. Interviews revealed that the resident had not been assessed for the ability to self-care for the ostomy, and no demonstration of the resident's ability to perform the care was requested by the staff. The Occupational Therapist noted that only certain parts of the self-care assessment were completed by therapy staff, and the nursing staff were responsible for the full assessment. However, there was no specific timeline for completing this assessment, and it was unclear if the nursing staff were aware of their responsibilities. The Assistant Director of Nursing and the Director of Nursing acknowledged that there was no specific assessment form for self-administration of treatments and that the resident's care plan and orders needed to be updated to reflect the resident's ability to perform ostomy care independently. Despite the resident's ability to self-administer ostomy care, the necessary documentation and physician's order were not in place, leading to a deficiency in the facility's compliance with its own policies.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Facility staff did not change a resident's colostomy pouch according to physician orders, as evidenced by blank spaces on the TAR for two consecutive months. An LPN confirmed that documentation of pouch changes is required, and the facility lacked a specific policy for colostomy care.
A resident with an ileostomy experienced improper care due to the use of an incorrect size ostomy wafer, which exposed too much skin and was cut too large. The resident's sister reported delays in changing the colostomy bag, leading to skin irritation. An LPN confirmed the incorrect wafer size during an observation. The resident's physician's orders specified a 1 3/4 cm wafer and regular bag checks, which were not followed, resulting in a deficiency.
A resident did not receive documented colostomy care on multiple occasions, as required by their care plan. Facility staff interviews revealed that CNAs were responsible for emptying and burping colostomy bags, while nurses were to change the bags and document the care. However, the eTARs lacked evidence of care being provided on several dates, indicating a failure to adhere to the facility's policy for licensed nurse-provided colostomy care.
A resident did not receive physician-ordered colostomy care on multiple occasions, as documented in the treatment administration record. The colostomy bag was not emptied during certain shifts, and the appliance was not removed, skin care was not provided, and the appliance was not reapplied for several days. An LPN confirmed that treatments are evidenced by signing off on the TAR, but this was not done. The facility's policy required documentation of the procedure, which was not followed.
A resident with a colostomy did not receive appropriate care due to the absence of physician's orders and inadequate documentation of colostomy care. An LPN confirmed the need for such orders to guide care, and the facility lacked a policy on colostomy management. The administrative staff was informed of these deficiencies.
Failure to Provide Ordered Colostomy Care and Documentation
Penalty
Summary
Facility staff failed to provide colostomy care and services as ordered for one resident. The resident had a physician's order, dated 11/19/22, to change the colostomy pouch every two to three days and as needed, with the treatment administration records (TARs) for April and May 2023 reflecting this schedule. However, review of the TARs for those months showed blank spaces, indicating that the colostomy pouch changes were not documented as completed during that time. An LPN confirmed that nurses are expected to sign off on the TAR when the colostomy pouch is changed. The facility was unable to provide a specific policy regarding colostomy pouch care.
Incorrect Ostomy Appliance Size and Care Deficiency
Penalty
Summary
The facility's staff failed to apply the correct size ostomy appliance and did not provide care to an ostomy according to the physician's order for one resident. The resident, who has an ileostomy, was observed to have the wrong size wafer applied, which exposed too much skin and was cut too large. This was confirmed during an observation by an LPN, who noted that the wafer needed to be cut smaller. The resident's sister also reported that the staff used the incorrect size wafer and that it took up to six hours for the staff to change the resident's colostomy bag when it was full, causing skin irritation. The resident, who was admitted to the facility with diagnoses including ileostomy status and malignant neoplasm of the sigmoid colon, was coded as having severe memory and decision-making impairments. The physician's orders specified the use of a 1 3/4 cm wafer and outlined specific care instructions, including checking and emptying the colostomy bag every four hours. However, these orders were not followed, leading to the deficiency. The facility's corporate nurse consultant confirmed the correct wafer size and indicated that the nursing staff had been educated on this matter.
Failure to Provide and Document Colostomy Care
Penalty
Summary
The facility staff failed to provide necessary colostomy care for a resident, identified as Resident #4, on multiple occasions. The clinical record review and electronic treatment administration records (eTARs) revealed that colostomy care was not documented as provided during several shifts in March, April, and May 2024. The resident's comprehensive care plan required colostomy care every shift and as needed, but the records did not show evidence of this care being administered on the specified dates. Interviews with facility staff, including a CNA and an LPN, indicated that while CNAs were responsible for emptying and burping colostomy bags, nurses were supposed to change the bags and document the care in the medical record. The facility's policy stated that colostomy and ileostomy care should be provided by a licensed nurse as ordered by the physician. Despite this policy, the lack of documentation in the eTARs suggests that the required care was not consistently provided or recorded. The deficiency was brought to the attention of the facility's administrative staff, including the administrator, assistant director of nursing, and regional director of clinical services, but no further information was provided before the survey exit.
Failure to Provide Colostomy Care as Ordered
Penalty
Summary
The facility staff failed to provide physician-ordered colostomy care for a resident, identified as Resident #479, on multiple occasions in February 2024. The resident's clinical record included orders to empty the colostomy bag as needed and every shift, and to remove the colostomy appliance, provide skin care, and reapply the appliance once every three days. However, the treatment administration record (TAR) showed that the colostomy bag was not emptied during the day shift on two specific dates, and the colostomy appliance was not removed, skin care was not provided, and the appliance was not reapplied for a period of six days. Nurses' notes also lacked documentation of these treatments being completed on the specified dates. During an interview, an LPN confirmed that treatments like colostomy care are evidenced by signing off on the TAR. The facility's policy on colostomy/ileostomy care required documentation of the procedure in the resident's documentation form, which was not adhered to in this case. The administrator and director of nursing were informed of these concerns, but no further information was provided before the survey exit.
Failure to Provide Colostomy Care
Penalty
Summary
The facility staff failed to provide appropriate colostomy care and services for a resident, identified as Resident #127, who was admitted with a colostomy. Upon review of the resident's clinical records, it was found that there were no physician's orders regarding the colostomy care, which is essential for guiding the nursing staff in providing necessary care. The records showed minimal documentation of colostomy care, with only two notes indicating that the colostomy bag was changed and emptied on specific dates. This lack of consistent documentation and absence of physician's orders highlights a deficiency in the facility's care for the resident's colostomy needs. During an interview, an LPN confirmed that there should be physician's orders for colostomy care, which typically include daily checks of the stoma site, routine colostomy care every shift, and instructions on when to change the colostomy wafer and bag. The facility's administrative staff, including the administrator and the director of nursing, were informed of this concern. Additionally, the facility did not provide a policy regarding colostomy care, further indicating a gap in their procedures for managing residents with colostomies.
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