Failure to Identify and Address Inconsistencies in Ostomy Care and Documentation
Penalty
Summary
The facility failed to ensure its Quality Assurance and Performance Improvement (QAPI) program effectively identified and prioritized problems related to ostomy care and documentation before these issues were discovered by surveyors. There were inconsistencies in the documentation and provision of ostomy care for two residents, both of whom had colostomies and intact cognition. For one resident, nursing progress notes showed irregular documentation of colostomy bag changes, with significant gaps in records. For the other resident, the admission assessment incorrectly documented the type of ostomy, and medication administration records (MAR/TAR) showed incomplete documentation of colostomy bag changes, with some entries missing entirely. Interviews and observations revealed that both residents experienced discomfort and emotional distress due to inadequate ostomy care. One resident reported that her colostomy bag had burst multiple times because it was not emptied in a timely manner, leading to stomachaches and missed therapy sessions. She also expressed a lack of confidence in the staff's ability to perform ostomy care. The other resident reported anxiety about taking constipation medication due to fear of another colostomy bag blowout and stated that weekend staff seemed untrained in ostomy care. Staff interviews confirmed that there was no formal training or skills checklist for ostomy care for new hires or annual competencies, and some staff had only received informal, hands-on training or training at previous facilities. The facility's QAPI and Quality Assessment and Assurance (QAA) activities did not identify or address these issues prior to the survey. The QAA committee had not discussed ostomy care concerns in their meetings, and the facility's grievance log contained no complaints regarding ostomies. The Director of Nursing (DON) and Administrator acknowledged that ostomy care training was not part of the facility's standard orientation or ongoing education, and that documentation practices for colostomy care were inconsistent and unclear. As a result, residents experienced discomfort, anxiety, and embarrassment, and refused necessary medications due to concerns about inadequate ostomy care.