Failure to Prevent Recurrent Nephrostomy Tube Dislodgement
Summary
The facility failed to provide necessary care and services to prevent the recurrent dislodgement of a nephrostomy tube for a resident who was completely dependent on staff for all activities of daily living. The resident, who had significant medical conditions including chronic respiratory failure, anoxic brain damage, cardiac arrest, and quadriplegia, experienced multiple episodes where the nephrostomy tube became dislodged, resulting in repeated transfers to a general acute care hospital for invasive procedures. The care plans reviewed did not include specific interventions aimed at preventing the dislodgement of the nephrostomy tube, despite the resident's high risk and history of such incidents. Staff interviews revealed that the resident was unable to move or pull out the nephrostomy tube independently, and the likely cause of dislodgement was attributed to staff actions during care activities such as turning, repositioning, and bathing. Several staff members, including CNAs, LVNs, and RNs, acknowledged witnessing the tube dislodged on multiple occasions and indicated that the tube could be easily hidden under skin folds or not properly secured during care. The facility's policy and procedure for nephrostomy care required checking the placement and integrity of the tube, but there was no evidence that unlicensed staff received competency training specific to nephrostomy tube care. Documentation and interviews indicated that the care plans were updated after each incident but continued to lack preventive interventions for tube dislodgement. The repeated failure to implement effective measures to secure the nephrostomy tube and ensure staff competency in its care led to ongoing complications for the resident, including multiple hospitalizations and exposure to further medical risks.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with a colostomy and parastomal hernia did not receive appropriate colostomy supplies when staff repeatedly used urostomy bags instead of correctly sized colostomy pouches, leading to fecal leakage and strong odors. A CNA reported that proper 38 mm colostomy bags had been unavailable for months, with only smaller 28 mm pouches in stock, and demonstrated having to rip urostomy bags to fit the stoma, which caused stool to clog the urine anti-reflux valve and back up. The DON, responsible for ordering supplies, initially stated the clear pouches were colostomy bags but later confirmed they were urostomy bags after observing care and an inventory showed only a partial box of 28 mm colostomy pouches. The resident, who values religious participation, reported embarrassment over the transparent, leaking pouch and associated odors and had previously voiced dissatisfaction with the current supplies.
A resident with a history of rectal cancer, severe cognitive impairment, and a colostomy had care plan interventions and physician orders directing staff to monitor the ostomy, empty the pouch, and change it as needed each shift, as well as to monitor the peri-stoma area. While the MAR/TAR reflected that the pouch was checked every shift, the record contained no documentation that the colostomy pouch was fully changed or that stoma care was performed. During interviews, the DON could not state how often stoma care and complete bag changes occurred, and the Administrator noted the resident used a one-piece pouch system. This lack of documented full pouch changes and stoma care conflicted with facility policy requiring regular pouch changes and skin care around the stoma.
A resident with obstructive uropathy, toxic encephalopathy, and muscle weakness had a physician order for an RN to flush a left nephrostomy tube with 10 mL NSS every morning and as needed to maintain patency. Review of the MAR/TAR showed that the ordered morning flushes were missed on three separate days, and progress notes contained no explanation for the missed treatments or any indication that staff attempted to complete the flushes later in the day. The DON was informed that this failure to follow nephrostomy care orders did not comply with facility policy and applicable state nursing service regulations.
Two residents experienced repeated colostomy leaks when staff did not consistently provide effective colostomy care in accordance with facility policy. One cognitively intact resident returned from the hospital and was twice observed with a leaking colostomy bag, while CNAs acknowledged they had not checked him promptly and that nurses were responsible for colostomy care. Another resident with severe cognitive impairment was observed with a leaking colostomy and stool on his abdomen after a recent colostomy change, and an LPN stated the appliance should not leak and did not know who had changed it. A nurse consultant confirmed that nurses are responsible for colostomy changes and that colostomies should not leak because this can cause skin irritation and infection.
A resident with a colostomy and care plan requiring colostomy care every shift and as needed repeatedly requested assistance to have a filling colostomy bag emptied. An agency CNA declined to perform the task and did not promptly notify an RN or LPN, and the PM receptionist routed the resident’s calls to voicemail instead of overhead paging nursing staff or a supervisor. As a result, the resident ultimately called 911, and when staff entered with medications they were unaware of the colostomy care need, finding the bag leaking feces, contrary to the facility’s ostomy care policy.
A resident with cognitive impairment, sepsis, and a colostomy did not receive documented colostomy care or appliance changes over extended periods, and there were no physician orders for changing or emptying the colostomy appliance. Review of the clinical record showed no entries reflecting ostomy care from admission until transfer to the hospital and again after readmission, and the DON confirmed the absence of both ostomy orders and documentation of colostomy care.
Failure to Provide Appropriate Colostomy Supplies and Care
Penalty
Summary
The facility failed to provide appropriate colostomy supplies for a resident with a history of colon cancer, colostomy, and parastomal hernia, resulting in ongoing problems with ostomy management. The resident had a BIMS score indicating moderate cognitive impairment and a care plan goal that ostomy care would be managed appropriately and stool would not leak. A CNA reported that staff had been using urostomy bags on the resident’s colostomy site for months because the correct 38 mm colostomy pouches were not in stock, and only 28 mm colostomy pouches were available. During an observation of colostomy care, the resident’s transparent ostomy bag was nearly full of feces, with fecal matter leaking from the upper right portion of the stoma and a strong, noxious odor in the room. The CNA obtained a urostomy bag from the resident’s nightstand and demonstrated that the plastic had to be ripped to fit the resident’s stoma and that the bag contained an anti-reflux valve designed for urine, which the CNA stated became clogged with stool and led to backups and fecal leakage. The DON, who was responsible for ordering medical supplies, initially stated the clear pouches in use were colostomy bags and that the facility was working on obtaining opaque bags per the resident’s preference. However, when asked to oversee the colostomy care, the DON confirmed that the pouch in use was a urostomy bag and acknowledged that using a urostomy bag instead of a colostomy bag could restrict fecal flow and lead to backup, leakage, or infection. An inventory of the supply closet revealed only a partial box of 28 mm colostomy pouches, with no appropriate-sized colostomy bags available for the resident. The resident reported significant embarrassment related to the transparency of the pouch and the associated odors from leakage, stating that he had not previously experienced such issues with his colostomy and that he had requested a different type of pouch. He also reported that participation in religious services was very important to him but that he sat in the back and avoided socializing due to concerns about the appearance and smell of his colostomy bag.
Failure to Document and Provide Complete Colostomy Pouch Changes and Stoma Care
Penalty
Summary
The deficiency involves a failure to provide and document appropriate colostomy care and services for a resident with a history of rectal, rectosigmoid, and anal cancer who had undergone an abdominoperineal resection and had a colostomy. The resident was severely cognitively impaired and had both an indwelling catheter and an ostomy. The care plan, revised on 6/18/24, directed staff to monitor and record bowel movements by emptying the ostomy pouch, monitor and record the peri-stoma condition, and provide and maintain appropriate ostomy supplies. A physician’s order dated 2/26/26 required staff to check the colostomy pouch every shift for patency and, if full, to empty or change it every shift and as needed. The March 2026 MAR/TAR showed that the colostomy pouch was monitored every shift as ordered. However, the clinical record lacked documentation that the colostomy pouch was ever fully changed or that stoma care was provided, despite the resident’s ongoing need for ostomy management. During interviews, the DON was unable to provide information about the frequency of stoma care and complete bag changes, and the Administrator stated that the resident’s colostomy pouch was a one-piece system, with no separate wafer or pieces to change. The facility’s own policy on colostomy, urostomy, or ileostomy care required regular changing of the pouching system to avoid leaks and skin irritation, limiting removal to no more than once a day unless there was a problem, and cleaning and drying the skin around the stoma. The absence of documentation of full pouch changes and stoma care, in the context of these orders and policies, constituted the identified deficiency.
Failure to Follow Physician Orders for Nephrostomy Tube Care
Penalty
Summary
Surveyors identified that the facility failed to provide nephrostomy care and services consistent with physician orders for one resident. Facility policy titled "Ostomy Care" dated 4/17/25 stated that ostomy care would be provided for residents with a urostomy, colostomy, or ileostomy to maintain peristomal skin integrity, monitor the stoma, manage odor, and promote self-esteem. Resident R1 was admitted on an unspecified date and had diagnoses including obstructive uropathy, other toxic encephalopathy, and muscle weakness. Physician orders dated 12/31/25 directed that the resident’s left nephrostomy tube be flushed daily in the morning with 10 mL normal saline solution (NSS) to keep the tube patent, and as needed, by an RN only. Review of the MAR/TAR for February 2026 showed that the ordered morning nephrostomy tube flushes were missed on three days (2/2/26, 2/5/26, and 2/6/26). The clinical record, including progress notes, did not contain any explanation for why the flushes were not administered as ordered, nor any documentation that staff attempted to complete the flushes later in the day if they were not done in the morning. During an interview on 2/24/26 at 3:06 p.m., the DON was informed that the facility had failed to provide nephrostomy care and services consistent with the physician’s orders for this resident, constituting noncompliance with 28 Pa. Code 211.10(c) and 211.12(d)(1)(2)(5).
Failure to Provide Effective Colostomy Care Resulting in Repeated Leaks
Penalty
Summary
The facility failed to follow its colostomy care policy for two residents, resulting in repeated colostomy leaks. One cognitively intact male resident with a diagnosis including colostomy and UTI was observed on two consecutive days with a leaking colostomy bag, first on his return from the hospital and again the next day with a new bag leaking through the base dressing. A CNA stated she had not had a chance to check on him after his hospital return and that nurses were responsible for colostomy care, and another CNA confirmed the colostomy should not leak. A second male resident with severe cognitive impairment was observed with a leaking colostomy and a moderate amount of stool on his abdomen, and an LPN stated the colostomy had been changed that day, did not know who changed it, and acknowledged it should not leak. The nurse consultant confirmed that nurses are supposed to change colostomies and that they should not leak because this can cause skin irritation and infection. The facility’s colostomy care policy stated that the purpose of colostomy care is to prevent infection and skin irritation. These observations, staff interviews, and the facility’s own policy demonstrate that colostomy care was not consistently provided in a manner that prevented leakage for the two residents reviewed for colostomy care.
Failure to Provide Timely Colostomy Care and Response to Resident Requests
Penalty
Summary
The facility failed to provide necessary colostomy care for a dependent resident who required assistance with emptying her colostomy bag. The resident, who had diagnoses including irritable bowel syndrome and an encounter for a colostomy, had a care plan dated 10/20/2023 that required colostomy care every shift and as needed. On the evening of 2/1/2026, the resident activated her call light around 8:00 p.m. and requested that an agency CNA empty her colostomy bag. The CNA stated she did not feel comfortable performing the task. The resident then asked the CNA to inform the nurse because the colostomy bag was filling up. After approximately 30 minutes, the resident again used the call light; the same CNA returned and reported she had asked other CNAs, but not the nurse, and said she would ask the nurse. The resident subsequently called the front desk multiple times requesting to speak with a supervisor. The AM receptionist stated that when residents call the front desk, she overhead pages the supervisor or nurse to the room. However, the PM receptionist reported that on the night in question, she transferred the resident’s calls to the voicemail of the unit manager and house supervisor and did not overhead page. The unit manager and DON both stated they expected the receptionist to overhead page and the CNA staff, including agency staff, to notify the nurse when there is a skill-related issue or when a resident requests to see the nurse. The executive director stated the resident should not have had to call 911 for assistance. When emergency services arrived, the agency nurse entered the room with medications and was unaware the resident needed colostomy care, at which point the resident’s colostomy bag was leaking feces. The facility’s colostomy care policy dated 6/30/2025 required that ostomy appliances be emptied every shift and as needed.
Failure to Provide and Document Colostomy Care and Orders
Penalty
Summary
The facility failed to provide ordered and documented colostomy care for a resident who was cognitively impaired, required staff assistance for daily care, had a diagnosis of sepsis, and was admitted with a colostomy. The facility’s colostomy care policy required care per physician orders to provide good skin care and monitor the stoma and surrounding skin, but review of the clinical record showed that from the date of admission with a colostomy until the resident was sent to the hospital, there was no documentation that the ostomy appliance had been changed or that colostomy care was provided. After the resident was readmitted, there was again no documentation of ostomy appliance changes or colostomy care for an extended period. In addition, there were no physician orders in the record for changing or emptying the colostomy appliance, and the DON confirmed that there were no ostomy orders and no documented evidence that colostomy care was being provided. This lack of physician orders and absence of documented colostomy care for the resident’s ostomy appliance constituted the deficiency identified by surveyors under 28 Pa. Code 211.12(d)(5) Nursing Services.
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