Failure to Monitor Ileostomy Site as Ordered
Penalty
Summary
The facility failed to adhere to physician orders by not monitoring a resident's ileostomy site every shift as required. The resident, who was admitted with an ileostomy and other medical conditions such as chronic obstructive pulmonary disease and bipolar disorder, had a care plan in place that included monitoring the stoma site for signs of infection or skin changes every shift. However, the Treatment Administration Record (TAR) for April 2025 showed multiple instances where the stoma site was not monitored as per the physician's order, including specific dates and shifts where the monitoring was missed. The resident expressed concerns about the lack of proper ileostomy care, and a nurse consultant confirmed that there were missed monitoring instances according to the TAR. The facility's policy on colostomy/ileostomy care requires documentation of care provided, including any signs of infection or skin issues, but this was not consistently followed. This deficiency was identified through observation, interview, and record review, highlighting a failure in the facility's compliance with the prescribed care plan for the resident.