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:
Ostomy care was not provided or documented as ordered for two residents. One resident with an ileostomy and abdominal surgical incision had no documented wound care, stoma assessment, or output monitoring despite hospital and NP orders, and was later sent to the ER with a prolapsed stoma. Another resident with a colostomy reported the appliance was only changed when it failed and had worn the same bag for about a month; the DON confirmed there were no orders for stoma monitoring, emptying, or changing the appliance.
Inadequate urostomy care and monitoring led to a deficiency for a resident with neuromuscular bladder dysfunction and paraplegia. The resident’s pouch order was changed from routine changes every 3 days to PRN without documented rationale or criteria, and the record lacked guidance for emptying frequency. Family and CNA observations described a pouch that was often full, detached, or dirty, with urine spilled and collected by towels, and the resident was later hospitalized with septic shock secondary to UTI and bacteremia.
A resident with an ileostomy, intact cognition, and orders for pouch changes, skin protection, and behavior monitoring had those care instructions missing from the MAR/TAR. Progress notes documented fidgeting with the ileostomy bag and other related behaviors, but the MAR did not show the behaviors, non-drug interventions, or outcomes, and the DON stated the treatment orders should have been transcribed and documented.
Nephrostomy Tubing Placed Above Kidney Level: A resident with bilateral nephrostomy tubes was observed with the tubing routed up and over the back of a wheelchair and placed in a pouch above kidney level, contrary to facility policy requiring drainage bags to remain below the kidneys. The resident had a history of UTIs, kidney calculus, CKD, hydronephrosis, neurogenic bladder, and sepsis, and the care plan directed that the catheter bag and tubing be kept below bladder level at all times. The DON and CNA both stated this placement was not appropriate.
A resident with bilateral nephrostomy tubes, CKD, anemia, and tachycardia did not receive documented tube monitoring and care as ordered. The record lacked orders for site assessment, infection monitoring, insertion-site care, barrier precautions, and post-flush output monitoring, and the resident was not observed wearing the ordered abdominal binder. After returning from the hospital, progress notes did not document the tubes, an RN was unable to unclamp one tube during care, the dressings were undated, and the resident stated staff had not been caring for the tubes.
A resident with a suprapubic catheter and colostomy did not receive ordered care consistently, with multiple missed documentation entries for catheter and colostomy care across several shifts. During observation, an LPN provided catheter care without a gown under contact precautions and did not clean down the catheter, stating she was unsure of the procedure. Later, the resident’s colostomy bag was found loose with stool on the abdomen, and the resident said she had waited two hours for help.
Ostomy Care Not Provided or Documented as Ordered
Penalty
Summary
The facility failed to ensure ostomy care was provided as ordered and as recommended for two residents with ostomies. For one former resident with a history that included hypotension, diabetes, chronic kidney disease, cerebral infarction, sepsis with acute organ dysfunction, septic shock, endocarditis, perforated bowel, cardiac arrest, and a prolapsed ostomy, the record showed care plan interventions for emptying the ostomy bag each shift and monitoring skin around the stoma, but there was no care plan direction for changing the ostomy appliance or measuring output. The record also lacked treatment orders and documentation for the abdominal surgical incision with retention sutures that had been identified on hospital discharge instructions, and there was no order for daily stoma assessment, peristomal skin monitoring, or output monitoring as later recommended by the NP. The former resident was sent to the hospital after asking for help changing the ostomy bag multiple times during a shift, with exposed intestine noted when the bag was removed. Hospital records documented a prolapsed ostomy with approximately 7.5 to 8 inches of bowel protruding from the abdomen and a 1 cm wound dehiscence. On return to the facility, the NP documented an abdominal surgical wound and ordered ostomy care and monitoring, including daily stoma assessment, peristomal skin monitoring, and recording ostomy output every shift, but the chart contained no documentation that these orders were carried out as written. Skin checks and progress notes referenced an abdominal incision, but they did not include wound measurements, description, or details about the retention sutures. For the other resident, who had diabetes, heart failure, sepsis, hypertension, and a colostomy, the care plan included emptying the ostomy bag each shift and monitoring skin around the stoma, but there were no orders for changing the ostomy bag, monitoring the stoma site, or documenting when the appliance had last been changed. The resident stated the appliance was only changed when it ruptured or fell off and that the current bag had been worn for about a month, while the bag observed by surveyors had dark brown and black substance surrounding the appliance and on the bag. The DON confirmed there were no colostomy orders for monitoring the stoma site, emptying the bag, or changing the bag, and there was no documentation showing when the bag had last been changed.
Inadequate Urostomy Care and Monitoring
Penalty
Summary
Failure to provide appropriate urostomy care was identified for one resident with neuromuscular dysfunction of the bladder and paraplegia. The resident’s physician order for the ileovesicotomy/urostomy pouch was changed from changing every 3 days to changing as needed, but the record did not include a rationale for the change or define when a pouch change would be necessary. The record also did not include guidance for how often the pouch should be emptied, and the treatment record showed the pouch was documented as changed only two times during December 2025 through February 2026. Family and staff reported ongoing problems with the resident’s urostomy care. The family member stated she observed towels on the floor covered in urine, the pouch becoming so full that seams would give away, and dirty pouches, and said concerns were raised through meetings and grievance forms without change. A CNA reported the pouch frequently became detached and urine was collected with towels while staff reattached it, and also observed the pouch full and bulging on multiple occasions with the room frequently smelling of urine. The resident was later sent to the hospital with fever, abnormal vital signs, and confusion, and hospital paperwork showed septic shock secondary to urinary tract infection and bacteremia.
Failure to Document Ileostomy Care and Behavior Monitoring
Penalty
Summary
The facility failed to ensure that care and services for a resident's ileostomy were provided and failed to monitor and document the resident's behaviors related to the ileostomy in the medical record. The resident was admitted with diagnoses including encounter for attention to ileostomy, need for assistance with personal care, long-term use of immunosuppressive biologic medication, dependence on renal dialysis, and heart transplant status. The resident's MDS indicated intact cognition with a BIMS score of 15 out of 15 and that partial or moderate assistance was required for ostomy hygiene. The care plan identified anxiety related to fear of ileostomy leakage and ostomy supply availability, and physician orders directed that the ileostomy bag be changed every three days and as needed, with specific pouching system instructions and skin protection measures. Additional orders directed staff to monitor target behaviors related to use of alprazolam, including crying, fidgeting with the ileostomy, inability to sleep, and restlessness, and to complete monthly psychotropic medication reviews. Review of the MARs and TARs for January, February, and March 2026 showed that the ileostomy bag change orders and ileostomy care instructions did not appear on the MARs or TARs. Progress notes documented behaviors directed toward the ileostomy bag on multiple dates, but the February and March MARs did not document any behaviors, non-drug interventions, or outcomes related to those events, and there was no evidence of staff interventions to address the behaviors. The DON stated that the pouch system changes should have been documented on the MARs or TARs, that treatment orders should have been transcribed by the nurse who received the order, and that touching and fidgeting with the ileostomy bag documented in progress notes should have been documented in the behavior monitoring section of the MAR.
Nephrostomy Tubing Placed Above Kidney Level
Penalty
Summary
The facility did not ensure that a resident with bilateral nephrostomy tubes received care consistent with professional standards of practice. On 05/18/26, a surveyor observed the resident’s nephrostomy tubes placed up and over the back of the wheelchair and tucked into a pouch on the back of the chair above kidney level. The facility policy titled, Nephrostomy and Cystostomy Tube Care and Maintenance, states that residents with nephrostomy or cystostomy tubes will receive care consistent with professional standards of practice and that the drainage bag must be kept below the level of the kidneys at all times. Record review showed the resident was admitted with bilateral nephrostomy tubes related to a history of urinary tract infections, calculus of kidney, chronic kidney disease, hydronephrosis, neurogenic bladder, and a history of sepsis. The care plan included an intervention to position the catheter bag and tubing below the level of the bladder at all times. During interview, the DON stated nephrostomy drainage bags should be placed below the kidneys so urine flows down, and agreed it was not standard of practice for the tubes to run up and over the back of a wheelchair into a pouch above kidney level. A CNA also stated the tubing should be beside the resident and not hung over the wheelchair back.
Nephrostomy Tube Care Not Properly Provided
Penalty
Summary
The facility failed to provide nephrostomy tube monitoring and care for a resident with bilateral nephrostomy tubes. The resident had diagnoses including tachycardia, anemia, and chronic kidney disease, and her care plan dated 5/14/24 identified that she had nephrostomy tubes. A treatment order dated 8/22/25 indicated she had nephrostomy tubes for the left and right kidneys and that dressings should be changed on shower days on Monday and Thursday. However, the record lacked orders to observe the sites for signs and symptoms of infection, placement, care of the insertion sites, enhanced barrier precautions, and monitoring for output after flushing with 10 ml of saline. The resident was also not observed wearing an abdominal binder as care planned. After the resident returned from the hospital on 5/13/26, her progress notes lacked documentation of the nephrostomy tubes. On 5/21/26, RN 8 was observed providing care and was able to unclamp the left tube but unable to unclamp the right tube; the tubes had dressings covering the insertion sites, but they were undated. During interview, the resident stated staff had not been caring for her tubes since she returned from the hospital. The MA from the nephrologist office stated the dressings should be completed to the insertion sites and the tubes could be flushed if they were clamped. The DON stated the facility was changing the dressings two times per week and flushing the tubes daily.
Missed and Improper Catheter and Colostomy Care
Penalty
Summary
The facility failed to provide urinary catheter care according to professional standards of practice and failed to provide urinary catheter and colostomy care in a timely manner for Resident #49. The resident was admitted with diagnoses including cerebral infarction, epilepsy, type 2 diabetes, chronic kidney disease, dysfunction of the bladder, and Bell’s Palsy. The care plan identified the resident as at risk for complications related to a neurogenic bladder with a suprapubic catheter and a colostomy, and the MDS showed impaired cognition and dependence on staff for toileting. Physician orders required colostomy care every shift and suprapubic catheter care every shift and as needed. Review of the TAR showed multiple dates in March, April, and May 2026 when catheter care and colostomy care were not documented as provided. During observation on 05/12/26, an LPN performed catheter care while wearing gloves but no gown despite contact precaution signage on the door. The LPN cleaned around the catheter site and on each side of the catheter but did not clean down the catheter, stating she was unaware she had to wear a gown and did not clean the catheter because she did not want to dislodge it. Further observation on 05/14/26 found the resident’s colostomy bag had come loose and loose stool was over the resident’s abdomen. The resident stated she had been waiting two hours for someone to clean her up and put on a new colostomy bag. The DON and nursing staff later stated they were unaware the bag had come loose until it was brought to their attention. The facility policy for suprapubic catheter care directed staff to clean around the catheter, remove crusted material at the insertion site, and rinse and dry the area well, and the charting policy required documentation of treatments or services performed.
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