Failure to Obtain and Document Colostomy Care Orders
Penalty
Summary
The facility failed to ensure that a colostomy care order was in place for a resident who had undergone a total colectomy with ileostomy. Upon review of clinical records, it was found that there were no physician orders for colostomy care or documentation of such care in the resident's care plan or Medication Administration Record. The resident, who had a history of anoxic brain damage, acute respiratory failure, and use of a gastrostomy and tracheostomy tube, was readmitted to the facility after surgery with a colostomy, but the necessary orders for ongoing colostomy care were not present in the electronic health record. Interviews with facility staff, including a CNA, RN, and the DON, confirmed that the resident had a colostomy bag and that standard practice was to check and change the bag regularly. However, staff were unable to locate any formal order for colostomy care in the resident's records. Additionally, documentation revealed inconsistencies in the recording of bowel and bladder checks, with several days showing no data recorded. The facility's policy required that treatments and orders be consistent with safe and effective prescribing principles, but this was not followed in the case of the resident's colostomy care.