Failure to Investigate and Prevent Neglect in Ostomy Care
Penalty
Summary
A deficiency occurred when a resident with a colostomy, who was cognitively intact and had diagnoses including diverticulitis and muscle weakness, reported that an LPN removed their colostomy bag and, upon being unable to find a replacement that fit, retrieved the soiled bag from the garbage, cleaned it with mouthwash and bleach, and reapplied it. The resident stated this did not cause pain or discomfort but made them feel nervous. The facility's policy required prompt and thorough investigation of any reports of abuse or neglect, and specified procedures for ostomy care, including the use of clean supplies and proper documentation. The LPN involved admitted to not seeking assistance or checking the supply room for the correct ostomy bag size, instead reusing the soiled bag after cleaning it with mouthwash and bleach. The LPN also stated that the resident's call bell had been ringing for about an hour before the situation was addressed, and that she did not gather supplies before entering the room. Other LPNs interviewed confirmed that standard practice is to gather new supplies before performing ostomy care and that nurses, not aides, are responsible for this care. During an observation, it was confirmed that multiple sizes of ostomy supplies were available in stock at the facility. The Director of Nursing acknowledged that the facility failed to ensure the resident was free from neglect in this instance. The incident was not promptly and thoroughly investigated as required by facility policy, and the actions taken by the LPN did not align with established procedures for ostomy care.