Failure to Provide Consistent Colostomy Care
Penalty
Summary
The facility failed to provide colostomy care and services consistent with professional standards of practice for a resident, identified as Resident R39. The facility's policy on ostomy care requires that residents receive care in line with professional standards, the comprehensive person-centered care plan, and the resident's goals and preferences. However, a review of Resident R39's care plan and physician orders revealed discrepancies. The care plan did not reflect the physician's order to change the ostomy appliance every three days and as needed, instead indicating a change every seven days. This inconsistency led to the resident's ostomy appliance not being changed as ordered. Further investigation showed that the Treatment Administration Record (TAR) for December 2024 did not document the required change of the ostomy appliance on the specified date. Interviews with Resident R39 and staff confirmed that the appliance had not been changed according to the physician's orders. The Nursing Home Administrator acknowledged the failure to provide care consistent with professional standards for Resident R39, as confirmed by the Licensed Practical Nurse, Employee E15, who noted that treatments are signed off in the electronic record when completed. This deficiency was identified during a survey, highlighting a lapse in adherence to the facility's policies and physician orders.
Plan Of Correction
Resident R39's ostomy was immediately changed, and the care plan was updated. Like resident's ostomy orders were audited. Care plans were audited for like residents. Education was provided to licensed nursing staff by DON or designee on ensuring that all residents with ostomy orders include the following: the frequency of changes for the ostomy. Audits will be completed by DON or designee on ostomy care in AM clinical 3 times weekly for 4 weeks and monthly x 1 month. Audit results will be reviewed through the monthly QAPI process/meeting.