Failure to Provide Ostomy Care for Resident
Penalty
Summary
The facility failed to provide appropriate ostomy care for a resident with an ileostomy, as outlined in the resident's care plan. The care plan required staff to keep the skin around the stoma clean and dry, monitor for skin irritation, and observe the stoma for unusual changes. However, there was no evidence in the clinical record that ostomy care was provided or that supplies were changed from the time of the resident's admission until six days later. This lack of documentation was confirmed by the Director of Nursing. The resident, who had a diagnosis of dementia, was admitted to the facility without any physician orders for ostomy care until six days after admission. The orders, once in place, specified that the ileostomy wafer should be changed every three days and the ileostomy bag once daily or as needed. A family member reported that the resident's ostomy supplies had not been changed since admission, highlighting the facility's failure to adhere to the care plan and document the necessary care.
Plan Of Correction
Resident 158 received ostomy care immediately. Physician orders for Resident R158 were updated to include ostomy care orders. Current residents with an ostomy were audited to ensure ostomy care physician orders were in place. DON and/or designee is providing staff with education related to timely implementation of ostomy physician orders. DON/designee will perform audit of new admissions to ensure ostomy orders are present. Audit will be conducted 2x a week x 4 weeks then, 1x a week x 4 weeks then, 2x a month x 2 months then, 1x a month x 2 months. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee until monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings during QAPI.