Failure to Notify Physician and Document Urostomy Care
Summary
A deficiency occurred when a resident with a urostomy did not receive care consistent with professional standards, the care plan, and physician orders. The resident, who had multiple complex diagnoses including multiple sclerosis, bladder cancer, and a history of acute pyelonephritis, was observed to have cloudy urine with white sediments in the urinary tubing. Despite this, staff failed to notify the physician of these abnormal findings, as required by both the resident's care plan and facility policy. Certified Nursing Assistant (CNA) observed the cloudy urine but did not report it to the Licensed Vocational Nurse (LVN), and the LVN only became aware of the issue after being informed later. The Director of Nursing (DON) and other staff confirmed that the physician should have been notified immediately about the abnormal urine appearance. Additionally, the facility failed to assess, monitor, and document the resident for signs of urinary tract infection (UTI) as indicated in the care plan. The care plan specifically required monitoring for symptoms such as pain, burning, blood-tinged urine, cloudiness, changes in urine output, and other signs of infection. However, review of the resident's progress notes and other documentation revealed that there was no consistent monitoring or documentation of these signs and symptoms. The Director of Staff Development (DSD) acknowledged that nurses did not document assessments of urine color, odor, or presence of sediments every shift, as required by policy. Furthermore, the facility did not follow the physician's order to monitor and document the resident's urine output in milliliters (ml) every shift. Instead, documentation in the Medication Administration Record (MAR) only indicated the number of times the resident urinated, not the actual volume, which was contrary to the physician's explicit instructions. The DSD and DON both confirmed that this failure to document urine output in ml could result in unrecognized urine retention. Facility policy also required accurate measurement and documentation of input and output, which was not followed in this case.
Plan Of Correction
F 691 F 691a. How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice On 4/30/25, LVN 1 immediately called MD to notify him of Resident 1 urinary tubing sediments and cloudy urine. ADON placed an order in PCC for monitoring of foley catheter output for Resident 1 on 05/01/25. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken ADON reviewed all other residents with foley catheter on 4/30/25 and noted no change of condition indicated, therefore, no notification to MD was required. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur DON performed one-to-one in-service on 4/30/25 to LVN 1 regarding proper documentation of urine output in milliliter (ml-unit of volume) as well as facility policy and procedure "Urinary Catheter Care". DON performed licensed staff in-service to LVN's and RN's on 4/30/25, 5/1/25, and 5/2/25 regarding appropriate documentation of foley catheter including quality and quantity of urine output in ml (ml-unit of volume) as well as policy and procedure "Urinary Catheter Care". How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. DON and/or designee to conduct random reviews of residents weekly with foley catheter to verify appropriate documentation including quality (sediments/hematuria/cloudiness) and quantity of urine output in ml (ml-unit of volume) and any change of condition(s). Director of Nursing to collect and review data and will report audit findings to the Quality Assurance Committee monthly for 3 months for review and evaluation. The Director of Nursing and/or Administrator to determine if continued auditing and monitoring is recommended after three months. Completion Date 5/22/25 F 691 F 691. b&c How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice DON performed one-to-one in-service to LVN 1 on 4/30/25 regarding proper documentation of monitoring urine output in milliliters as well as documentation and proper assessment of the quality of the output. DON also reviewed the importance of following physician order. DON also reviewed facility policy and procedure "Urinary Catheter Care" with LVN 1 on 4/30/25. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken ADON reviewed all other residents in the facility with foley catheter on 4/30/25 and found no other signs of UTI related to catheter care. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur DON performed one-to-one in-service on 4/30/25 to LVN 1 regarding proper documentation of urine output in milliliter (ml-unit of volume) as well as facility policy and procedure "Urinary Catheter Care". DON performed licensed staff in-service to LVN's and RN's on 4/30/25, 5/1/25, and 5/2/25 regarding appropriate documentation of foley catheter including quality and quantity of urine output in ml (ml-unit of volume) as well as policy and procedure "Urinary Catheter Care". How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. DON and/or designee to conduct random reviews of residents weekly with foley catheter to verify appropriate documentation including quality (sediments/hematuria/cloudiness) and quantity of urine output in ml (ml-unit of volume) and any change of condition(s). Director of Nursing to collect and review data and will report audit findings to the Quality Assurance Committee monthly for 3 months for review and evaluation. The Director of Nursing and/or Administrator to determine if continued auditing and monitoring is recommended after three months. Completion Date 5/22/25
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Inconsistent Colostomy Care: A resident with a colostomy, dementia, paraplegia, diabetes, and other complex diagnoses did not receive colostomy bag changes as ordered every 3 days. Interviews and record review showed the bag went unchanged for 6 days, while staff described only emptying or burping the pouch and not consistently tracking when it needed to be changed. The resident reported soreness and redness around the stoma, and the NP stated the bag should have been changed twice during that period.
Failure to document ordered ileostomy care for a resident with an ileostomy, impaired cognition, and total assistance needs. The resident’s order required ileostomy care every shift and wafer/pouch changes as needed, but the TAR showed no documented ileostomy care or replacements for two months, and tasks documentation also showed missed toileting hygiene entries. Staff said CNAs empty ostomies while nurses assess and replace appliances, and the DON confirmed there was no documentation to verify the care was completed as ordered.
Delayed Colostomy Supply Provision: Three residents with colostomy orders reported delays in receiving resident-specific supplies, including using personal supplies from home and waiting days for ordered items. One resident said staff once covered the colostomy site with a towel when supplies were unavailable. Staff gave conflicting accounts of how supplies were ordered and when they were delivered.
Failure to care plan and document frequent colostomy care. A resident with an open abdominal wound and leaking bowel contents had orders for frequent fistula and ostomy-related care, but the care plan and Kardex did not include colostomy goals, interventions, or monitoring. Staff said they relied on the Kardex for care instructions, and the resident was observed with a strong odor, flies on the blankets, and a gown saturated with drainage. The resident reported being left soiled for long periods, while the UM and CNO confirmed the colostomy care needs were not documented.
A resident with paraplegia and a colostomy had a care plan and MDS noting the ostomy, but the record contained no documentation that colostomy care was provided, the bag was changed, the stoma was cared for, or the ostomy site was assessed. There were also no physician orders for colostomy care, and the Nurse Consultant had no further information about the resident’s colostomy care.
A resident with an ileostomy and tremors was not receiving ordered colostomy assistance. The physician ordered nursing staff to change the appliance and provide colostomy care as needed, but the resident filed a grievance saying staff were not helping empty the bag. A CNA told the resident she should do it herself despite her tremors, and the DON later stated there was confusion about CNA responsibilities for colostomy care.
Inconsistent Colostomy Care
Penalty
Summary
The facility failed to ensure that a resident with a colostomy received care consistent with the resident’s care plan and physician orders. Resident #2 had diagnoses including dementia, paraplegia, type 2 diabetes, morbid obesity, colostomy status, and a pressure ulcer, and her care plan directed staff to monitor bowel output daily, change the colostomy bag as needed, and provide stoma care daily and as needed. The physician orders in effect required colostomy care every shift and changing the colostomy bag and wafer every 3 days. Record review and interviews showed that the resident’s colostomy bag was not changed for 6 days. The MAR showed the order for changing the colostomy bag and wafer every 3 days, but progress notes did not document a bag change on multiple consecutive days. During interview, the resident stated that some staff took care of the colostomy and some did not, that staff had not changed the bag for 6 days, and that the bag had just been changed that morning. She also stated that the skin around the colostomy was red and sore and that staff sometimes did not know how to let the air out of the bag. Staff interviews confirmed inconsistent colostomy care. An LVN stated the bag had been changed that morning and that the CNA staff could burp the bag but not change it. A CNA stated she emptied and burped the bag but that it was the nurse’s responsibility to keep track of when it needed to be changed. Other staff described emptying or burping the bag, but several did not recall a bag change occurring during the days in question. The NP stated the bag should have been changed twice in 6 days and that not changing it could cause the bag to become softer and leak more. The facility policy stated that residents who require ostomy services are to receive care consistent with professional standards of practice, the care plan, and the resident’s goals and preferences.
Failure to Document Ordered Ileostomy Care
Penalty
Summary
The facility failed to ensure ostomy care was provided and documented according to the physician’s orders for one resident with an ileostomy. The resident was admitted with multiple diagnoses including partial intestinal obstruction, ileostomy status, type 2 diabetes mellitus with chronic kidney disease, vascular dementia, muscle weakness, need for assistance with personal care, hypertensive heart and chronic kidney disease with heart failure, and obstructive sleep apnea. The quarterly MDS showed impaired cognition, full assistance needed for toileting, bathing, and personal hygiene, and that the resident was always incontinent of urine with bowel continence not rated because of the ostomy. Record review showed the order for ileostomy care every shift and for wafer and pouch changes as needed for leaking or non-adhering wafer. Tasks documentation from 06/21/2026 through 07/20/2026 showed 19 of 90 expected toileting hygiene tasks were not documented as completed. The TAR showed ileostomy care was documented appropriately in May except for 2 shifts, but no checks were documented for any ileostomy care or replacements in June and July. Staff stated CNAs empty ostomies and nurses assess, maintain cleanliness, and replace the appliance as ordered or when issues occur, and the DON confirmed there was no documentation to show whether ostomy care or appliance changes were completed according to the order.
Delayed Colostomy Supply Provision
Penalty
Summary
The facility failed to ensure that residents with colostomies were provided necessary medical supplies in a timely manner. During the complaint survey, three residents with physician orders for routine colostomy appliance changes reported delays in receiving supplies, and one resident stated staff had previously placed a towel over the colostomy site because supplies were not available. Another resident reported that staff had to search for supplies and that there had been a multi-day wait on a prior occasion, while a third resident said the facility had not provided updates after a supply request was submitted. Record review showed physician orders for colostomy appliance changes every 3 days for each of the three residents. Interviews with staff indicated that colostomy supplies were resident-specific and ordered through central supply, and that residents should not use their own supplies. However, one staff member stated supplies were only ordered monthly through a vendor, while another later clarified that supplies for hospital admissions were identified and ordered for next-day delivery. An email confirmed that supplies for the three residents were ordered after the concern was raised.
Failure to Care Plan and Document Frequent Colostomy Care
Penalty
Summary
Appropriate colostomy care was not provided for one resident with an open abdominal wound leaking bowel contents after intestinal fistula repair. The resident was admitted for rehabilitation following a recent intestinal fistula and laceration of the sigmoid colon, which required colostomy placement and drainage of the abdominal incision. Medical orders directed frequent fistula and wound care, including changing the wound immediately after a leaking colostomy appliance change and using skin barrier, ostomy rings, and a wound manager to help maintain a seal. However, the resident’s care plan and Kardex did not document goals, interventions, or monitoring related to the leaking colostomy, and staff reported they relied on the Kardex for resident cares. During observation, the resident was found with a strong odor, flies on the blankets, and a gown saturated with colostomy drainage, while the resident stated staff left them soiled for long periods and that the ostomy bag was not emptied frequently, causing it to leak more and overflow. The resident also stated they had been kept under blankets for hours to keep flies off and described the situation as cold, cruel, and callous treatment. Staff interviews confirmed the colostomy leaked frequently, that staff followed the Kardex for care instructions, and that the Kardex was not updated with colostomy care needs. The unit manager reviewed the care plan and Kardex and verified that colostomy cares were not documented there, and the chief nursing officer stated the colostomy should have been care planned and that clinical management was responsible for updating the care plan and Kardex.
Failure to Provide and Document Colostomy Care
Penalty
Summary
Facility failed to provide colostomy care and failed to assess the colostomy and the skin surrounding the ostomy for one resident with a colostomy. The resident had diagnoses including paraplegia related to trauma and colostomy. The care plan indicated an ostomy was present and that the stoma would be monitored for changes and ostomy care would be provided, and the admission MDS also indicated a colostomy was present. However, the record contained no documentation that colostomy care had been provided, that the collection bag had been changed, that stoma care had been completed, or that the ostomy site had been assessed. There were also no physician orders for colostomy care. During interview, the Nurse Consultant had no further information on the care of the colostomy.
Failure to Provide Ordered Colostomy Care
Penalty
Summary
The facility failed to provide colostomy care consistent with professional standards for a resident admitted with an ileostomy and diagnoses including scoliosis, fibromyalgia, and thyroid disease. Physician orders dated 01/20/26 required nursing staff to change the resident’s colostomy appliance one time a day, every three days, and as needed, and to provide colostomy care during both day and night shifts as needed. The care plan also directed staff to monitor the skin around the stoma and change the appliance as needed. The resident filed a grievance stating she was not receiving assistance with her colostomy bag. Nursing progress notes documented a CNA telling the resident she should empty the bag herself because she was independent, despite being informed the resident had tremors and could not empty it by herself. During interviews, the resident stated staff were not helping her with the colostomy bag and that tremors made it difficult for her to manage. The ST reported the resident had complained about not receiving help and said there were times when the bag was full and nurses did not assist. The DON stated there was confusion about what CNAs can and cannot do regarding colostomy care and said CNAs should empty colostomy bags for residents who use them. The UM stated colostomy care must be provided by nursing staff.
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