Failure to Develop Colostomy Care Plan
Penalty
Summary
The facility failed to develop and implement a care plan for a resident with a colostomy, as required by facility policy. The resident was admitted and readmitted with diagnoses including colostomy status, malignant neoplasm of the colon, and intestinal abscess. Documentation showed the resident required partial to moderate assistance with activities such as toileting hygiene, bathing, and personal hygiene, and had a colostomy site on the abdomen. Physician orders were in place for colostomy care, including cleansing the site and applying a colostomy bag, but there was no corresponding care plan in the resident's medical record. Interviews with facility staff, including a treatment nurse, registered nurse supervisor, and the DON, confirmed that a care plan addressing the resident's colostomy was not developed. Staff acknowledged that a care plan should have been created to guide nursing interventions, monitor the stoma site, and ensure continuity of care. Review of facility policy indicated that comprehensive, person-centered care plans with measurable objectives and timetables are required for each resident, but this was not followed for the resident in question.