Failure to Provide Consistent Colostomy Care and Documentation
Penalty
Summary
The facility failed to provide consistent and appropriate colostomy care for two residents who required such services, as evidenced by incomplete documentation, inconsistent care practices, and lack of staff training. Both residents had clear physician orders for colostomy care every shift and to change the colostomy bag as needed, but records showed gaps in documentation of care provided, including missing entries for bag changes and inconsistent recording of bowel movements. In one case, a resident's colostomy was incorrectly documented as an ileostomy/urostomy on the nursing admission assessment, and staff were not always able to accurately identify or document the type of ostomy present. Residents reported discomfort, anxiety, and embarrassment due to the inconsistent care. One resident experienced a very full colostomy bag that had not been emptied, resulting in stomachaches and three instances of the bag bursting since admission. The resident also expressed concern about staff knowledge and skill in providing colostomy care, noting that some staff appeared hesitant or unsure of the procedure. Another resident reported intentionally avoiding medications to prevent constipation out of fear of another 'blow out' after a previous incident, and described staff reluctance to assist with colostomy care. Observations confirmed that colostomy bags were sometimes left full and not emptied in a timely manner. Interviews with staff revealed a lack of formal training and inconsistent understanding of colostomy care responsibilities. Some CNAs and nurses reported receiving only hands-on or peer-to-peer training, and several staff members stated they had not received any ostomy care training at the facility. The facility's policy on colostomy care did not specify who was responsible for care, how often bags should be changed, or address emptying procedures. Documentation practices were inconsistent, with staff relying on verbal reports or incomplete written records to track when colostomy bags were last changed or emptied.