Failure to Provide Ordered Colostomy Care and Document Refusal
Penalty
Summary
A deficiency occurred when a resident with a colostomy did not receive colostomy care as ordered by the physician. The resident's medical record indicated a diagnosis of colostomy status, malignant neoplasm of the colon, and abscess of the intestine. The physician's order required the colostomy site to be cleansed with normal saline, patted dry, and a colostomy bag applied every dayshift. However, during observation, the treatment nurse only emptied the colostomy bag and did not perform the required cleansing or bag change. The nurse stated that she followed instructions from the resident's family member to only empty the bag and admitted to not documenting any refusal of care or notifying the physician, as required. Further review of the resident's medical chart showed no documentation of refusal of colostomy care or physician notification regarding any treatment refusal. The Director of Nursing confirmed that the physician's order was not followed and emphasized the importance of providing treatments as ordered. The facility's policy also required proper colostomy care and documentation of any concerns or refusals, which was not adhered to in this case.