Repeated Nephrostomy Tube Complications Due to Inadequate Care and Staff Training
Summary
A deficiency was identified when a resident with bilateral nephrostomy tubes experienced repeated complications, resulting in six transfers to the emergency department within a 120-day period. The resident, who is cognitively intact and has multiple comorbidities including neuromuscular bladder dysfunction and diabetic nephropathy, required specialized care for nephrostomy tubes. The care plan included interventions such as the use of an abdominal binder, regular assessment and documentation of drainage, monitoring for infection, and catheter care. However, the care plan also contained outdated interventions that were not relevant to the resident's current needs, such as references to a Foley catheter and voiding trials. Despite the care plan, the resident experienced multiple incidents of nephrostomy tube dislodgement, malfunction, and infection. Documentation revealed that tubes were frequently pulled out during transfers, particularly with the use of a Hoyer lift, and that staff sometimes improvised solutions, such as attaching a Foley catheter to the nephrostomy tube. The resident also developed infections requiring hospitalization and intravenous antibiotics. Interviews with staff and the resident indicated inconsistent use of the abdominal binder, with the resident discontinuing its use due to a rash, and staff not being fully aware of this change. Training for staff on nephrostomy tube care and safe transfer techniques was limited to verbal discussions and occasional meetings, with no formal competency assessment documented in the facility assessment. Surveyor interviews further revealed that staff had only minimal training on nephrostomy tube care, and that interventions to prevent tube dislodgement were not consistently implemented or updated based on the resident's feedback and clinical needs. The facility's failure to ensure staff competency, update care plans appropriately, and consistently implement interventions led to repeated medical interventions and hospitalizations for the resident.
Penalty
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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.
Failure to Monitor and Document Ileostomy Output: A resident with ostomy status developed abdominal pain and had no output in the ostomy pouch, but staff did not consistently empty, measure, or document the ileostomy output. An LPN noted severe pain and no fluids in the pouch, while the resident’s family later took the resident to the hospital, where the resident was diagnosed with a small bowel obstruction. The resident’s care plan did not reflect independent ostomy care or education about reporting pouch output.
Failure to Monitor and Assess Colostomy Care: A resident with a colostomy, prior abdominal surgery, and neurologic deficits was found with a leaking or overly full ostomy bag, and an RN from an outside clinic reported stool had leaked onto his lap and clothes during an appointment. A family member said staff often had to be told when the bag was full or leaking, while the chart lacked specific ostomy care orders and the care plan only said to change the appliance as needed.
A resident with an ileostomy and abdominal wall cellulitis received ostomy care from a CNA who changed the wafer but did not remove the paper backing, so it did not adhere properly. The resident told staff the care was being done wrong and asked for a nurse, while the DON and LPN later confirmed the CNA was not trained or competent to perform ostomy wafer changes and had no ostomy care education.
A resident admitted with a urostomy, indwelling catheter, MS, UTI, and dementia did not receive appropriate urostomy care because the facility did not have the proper supplies available. Records showed the resident still needed urostomy supplies after admission, and staff interviews revealed confusion about ordering and access to supplies, with the facility sometimes relying on the resident’s wife to bring in needed wafers and pouches.
Failure to provide appropriate ostomy care occurred when staff did not consistently burp and empty a resident's ostomy appliance, leaving it repeatedly filled with air. The resident, who had an ileostomy, moderate cognitive impairment, and diagnoses including functional quadriplegia and Ogilvie syndrome, reported that staff are not always good about burping or draining the bag and that the appliance has blown out and spilled contents several times. Staff said the task should be done every 2 hours, but not all staff were completing it.
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.
Failure to Monitor and Document Ileostomy Output
Penalty
Summary
The facility failed to follow the resident’s plan of care and accepted standards of practice for ostomy care by not monitoring, measuring, and documenting ileostomy output for one resident with ostomy status. The resident’s record showed diagnoses of colostomy status, and the care plan identified a potential risk for complications related to an altered elimination device, with interventions to check the device, monitor for complications, and provide ostomy care. The care plan did not reflect that the resident would independently care for the ileostomy, nor did it show education about independently caring for the site or informing staff of pouch output. On the day of the event, staff and family described the resident developing abdominal pain and having no output in the ostomy pouch. A CNA stated she did not empty the pouch during her shift and said the resident emptied her own bag. An LPN later stated she did not empty the pouch during her shift, assessed the resident’s abdomen, found no fluids in the ostomy bag, and heard the resident report no bowel movement for 2 to 3 days and severe pain. The LPN documented abdominal pain and refusal of treatment, but also stated she did not document the abdominal assessment or the finding of no fluids in the pouch. The resident’s family member reported that the resident complained of abdominal pain, was taken to the nurse station, and later went to the hospital by private vehicle after continued distress. The nurse practitioner stated staff should have monitored and documented ileostomy output and should have been informed of all details, including the severe pain and lack of pouch output. The physician stated the facility should have been monitoring and documenting ileostomy output. The resident was admitted to the hospital and diagnosed with a small bowel obstruction.
Failure to Monitor and Assess Colostomy Care
Penalty
Summary
The facility failed to monitor and assess one resident with a colostomy. The resident was a Spanish-speaking male with a history of small bowel obstruction surgically repaired with colostomy placement, an abdominal abscess requiring IV antibiotics, and prior brain bleed with craniotomy that resulted in aphasia and one-sided weakness. During a telephone interview, an RN from an infectious disease clinic stated that when the resident arrived for an appointment, his colostomy was leaking stool onto his lap and clothes. During observation, the resident’s call light was on and he pointed to a colostomy bag that was full of stool. A family member stated that staff frequently had to be told when the resident’s colostomy was full or leaking. The resident also reported to the infectious disease physician that he had concerns about wound care and the ostomy bag leaking over the surgical site. Review of the E-TARs showed no colostomy orders for how often to check the bag, when to burp it, when to change the appliance or wafer, or how to monitor the stoma, stool amount, color, or consistency. The care plan only included changing the ostomy appliance as needed and noted that he wore an ileostomy product. The facility policy stated ostomy care includes releasing gas as needed, evaluating the ostomy site and surrounding skin, evaluating stool characteristics for changes, and emptying the ostomy bag.
Improper Ostomy Care by Untrained CNA
Penalty
Summary
The facility failed to provide nursing care and services consistent with professional standards of practice for a resident with an ileostomy and diagnoses including cellulitis of the abdominal wall, ileostomy status, and encounter for attention to colostomy. The facility policy stated ostomy care was to be provided in a manner that promoted dignity and resident health by maintaining cleanliness and skin integrity, preventing odors and infections, and applying the appliance per manufacturer recommendations while ensuring it was secured properly. The resident had physician orders to change the ostomy appliance, apply powder on irritated areas and ostomy barrier paste before applying the ostomy ring, and describe the stoma with each ileostomy appliance change. During the incident, CNA Staff A performed ostomy care for the resident and changed the whole appliance, including the wafer. The resident told staff that the care was being done incorrectly and stated that the paper portion of the wafer had not been removed, which prevented it from adhering properly. The resident also asked for a supervisor and repeatedly told staff that the ostomy care was not attached properly and that the aide should get a nurse. The DON and LPN Staff B both reported that the resident said the aide did not know what she was doing and that he was shushed when he tried to explain the problem. Staff interviews showed conflicting understanding of ostomy care responsibilities, with multiple CNAs stating they only emptied ostomy bags and that nurses changed bags and wafers, while the DON stated CNAs were not allowed to change ostomy wafers and had no training or competencies for ostomy care. Facility records confirmed CNA Staff A had no education on how to perform ostomy dressing changes and no competencies completed. The DON also confirmed that CNA Staff A was not trained on ostomy care or changing the wafer.
Urostomy Supplies Not Available for Resident Care
Penalty
Summary
The facility did not ensure appropriate urostomy care and services for a resident who required them. The resident was admitted with a urostomy and diagnoses including weakness, multiple sclerosis, urinary tract infection, dementia, and acquired absence of other parts of the urinary tract. The admission MDS indicated the resident had an indwelling catheter and an ostomy. A progress note dated 1/22/2026 stated the resident’s family member would bring temporary urostomy supplies, and the 24-hour status report for 1/21/2026 through 1/30/2026 showed the resident still needed urostomy supplies on 1/23/2026. Surveyor interviews and record review showed the facility did not have the proper supplies available for the resident’s urostomy needs. Medical Records-F stated a box of 10 urostomy pouches was ordered on 1/20/26 and shipped on 1/26/2026, but they did not know when it was received. Medical Records-F also stated staff were supposed to write needed items on a sheet in the medication room, while urostomy supplies were kept in the med cart, which Medical Records-F could not access. The DON was unsure of the ordering process, and an agency LPN stated the facility did not always have the rubber wafer for the resident’s urostomy and relied on the resident’s wife to bring them in. The DON and NHA stated specialty needs should be identified before admission and that central intake was supposed to notify the facility of needed supplies, but sometimes that information was not relayed.
Failure to Provide Consistent Ostomy Burping and Emptying
Penalty
Summary
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services was not met when staff failed to release the buildup of gas in Resident #13's ostomy bag. Clinical record review showed Resident #13 had a BIMS score of 12, indicating moderate cognitive impairment, and diagnoses including functional quadriplegia, ileostomy status, noninfective gastroenteritis, colitis, and Ogilvie syndrome. The care plan, revised 4/28/26, indicated Resident #13 required assistance from 1 staff member with colostomy care and emptying. Observation on 5/26/26 showed Resident #13's ostomy bag completely filled with air after bingo, and the resident stated staff are not always good about burping or draining the bag. The resident reported that when the bag is not burped, the appliance can blow out and spill its contents, and that this has happened several times. Another observation on 5/27/26 showed the ostomy appliance again full of air. Staff interviews indicated the bag should be burped every 2 hours, that outputs are charted twice a day, and that not all staff were completing the task. The DON stated staff would be expected to empty and burp ostomy appliances at the appropriate times. The facility policy stated residents requiring ostomy services will receive care consistent with professional standards of practice.
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