Failure in Colostomy Care for Two Residents
Penalty
Summary
The facility failed to provide colostomy care and services consistent with professional standards of practice for two residents. Resident R5, who was admitted with diagnoses including diabetes, Ogilvie's syndrome, and pressure ulcers, had a physician order for specific colostomy appliances. However, the care plan did not specify the type and size of the appliance, leading to confusion among staff. A registered nurse admitted to being unaware of the correct appliance size and type, relying instead on available supplies in the resident's room or the supervisor's office. An observation revealed that the ostomy supplies lacked visible type or size information. Resident R6, admitted with ulcerative colitis, malnutrition, and a history of stroke, also had a physician order for specific colostomy appliances. However, the care plan did not include a developed plan for the presence of an ostomy. An observation of Resident R6's room showed a mismatch between the supplies present and the physician's order. The Central Supply employee confirmed that sizes are listed on the shipping receipt, but this information was not effectively communicated to the staff. The Nursing Home Administrator and the Director of Nursing acknowledged the facility's failure to provide care consistent with professional standards.
Plan Of Correction
As of 03/28/25, colostomy care orders were reviewed and updated in the EMR per order for R5. Ostomy supplies were labeled and stored properly and care plan reviewed. As of 03/28/25, physician orders were clarified and entered per order for R6. The care plan was created and implemented to address ostomy care needs, risks of leakage, and maintenance of skin integrity. Incorrect supplies were removed from the resident's room, and the correct items were provided in clearly labeled original packaging. Central Supply updated the inventory records and verified product-match to orders. A facility-wide audit was completed for all residents with any type of ostomy (colostomy, ileostomy, or urostomy) to ensure orders were reviewed for completeness and accuracy, care plans were reviewed for alignment with physician orders and ostomy type, and supply availability, labeling, and product-match were verified in resident rooms. No adverse outcomes were identified during the audit. By 4/30/25, DON will conduct education for all licensed nurses, CNAs, and Central Supply staff on: - Ostomy care policy and procedures, to include: - Ostomy care protocols per professional standards - Matching product types and sizes to orders - Updating and referencing care plans before providing care - Labeling and organizing ostomy supplies in resident rooms DON/designee will conduct audits 5 times per week for 8 weeks, then monthly thereafter, of all residents with ostomies to ensure: - Product-match between orders, supplies, and usage - Proper labeling and organization of supplies - Care plan accuracy and staff documentation