Failure to Accurately Document and Provide Ordered Colostomy Care
Penalty
Summary
The facility failed to ensure accurate and complete documentation of colostomy care for one resident with a history of colostomy status, malignant neoplasm of the colon, and abscess of the intestine. The resident required partial to moderate assistance with toileting hygiene and had a physician's order for daily cleansing of the colostomy site with normal saline, patting dry, and applying a colostomy bag every dayshift. Review of the Treatment Administration Record (TAR) for the relevant period showed that the required colostomy care was documented as completed, but direct observation and staff interviews revealed that the care was not actually provided as ordered on at least one occasion. During observation, a nurse was seen only emptying the colostomy bag without performing the required cleansing or bag replacement. Interviews with two treatment nurses confirmed that one did not provide or document the care, while the other documented the care as completed despite not having performed or witnessed it. The Registered Nurse Supervisor and Director of Nursing both confirmed that facility policy requires accurate, complete, and timely documentation by the staff who actually provide the care. Review of the facility's documentation policy further emphasized the need for objective, complete, and accurate records of all treatments and services provided.