Failure to Provide Urostomy Supplies Resulting in Urine Leakage
Penalty
Summary
The facility failed to ensure the availability of appropriate urostomy supplies for a resident with a history of bladder cancer, dementia, and other urinary tract conditions. The resident, who was cognitively impaired and required assistance with activities of daily living, was observed multiple times with urine leaking from the urostomy site and a strong odor of urine present in and around the room. On several occasions, the resident was found without a functioning urostomy bag, resulting in urine saturation of the lower abdomen and the bedroom floor. Staff confirmed that the resident was completely out of urostomy bags and that attempts to use a colostomy bag as a substitute were unsuccessful, as it was not compatible with the resident's needs. Interviews with nursing and supply staff revealed a breakdown in communication and supply management. The nurse supervisor acknowledged that the resident had requested a new bag, but the correct supplies were not ordered in a timely manner. Central supply staff indicated they were not informed of the shortage until after supplies had run out, and there was difficulty obtaining the correct size. Facility documentation and policies required maintaining adequate stock of medical supplies and providing regular urostomy care, but these were not followed, resulting in the resident's needs not being met.