Improper Colostomy Care Results in Resident Burn Injury
Penalty
Summary
A certified nursing assistant (CNA) failed to provide necessary care and services to a resident with a colostomy, resulting in a burn injury. The CNA attempted to empty the resident's colostomy bag but was unable to remove all fecal matter. Instead of following facility policy and procedure, which prohibits direct care staff from putting fluids into the colostomy bag, the CNA left the room, obtained a cup of hot water, and poured it into the colostomy bag. During this process, the colostomy bag touched the resident's skin, causing a burning sensation and subsequent injury to the left thigh and abdomen. The resident, who was cognitively intact and able to make decisions, immediately reported pain and burning to the CNA, but the CNA did not promptly respond. The resident had to physically intervene to stop the procedure. The incident resulted in redness and, later, a blister on the resident's left thigh. The medical record documented the development of a burn wound, with measurements and a wound status of open, and the resident required pain medication and wound treatment as a result. Interviews with facility staff, including the CNA, LVN, DSD, and DON, confirmed that the CNA used hot water inappropriately and did not follow established protocols for colostomy care. Facility policy clearly states that CNAs are not permitted to put fluids into colostomy bags and should notify a supervisor if additional care is needed. The CNA admitted to not checking the water temperature and not using appropriate protective measures, such as a towel, which contributed to the resident's injury.