Nurse Aide Lacks Competency in Colostomy Care, Resulting in Resident Burn
Penalty
Summary
The facility failed to ensure that a nurse aide demonstrated competency in the skills and techniques necessary to care for a resident with a colostomy, as identified through the resident's assessment and care plan. The nurse aide, who had been employed for less than three months, was responsible for emptying a resident's colostomy bag but was not properly trained on the procedure during orientation or in CNA school. Instead, the aide learned from other CNAs, one of whom demonstrated pouring water into the colostomy bag, a practice not permitted by facility policy. During the incident, the nurse aide attempted to empty the colostomy bag but was unable to remove all fecal matter. The aide then left the room, obtained a cup of water from a dispenser, and poured it into the colostomy bag without checking the water temperature. The hot water came into contact with the resident's skin, causing a burning sensation and resulting in redness and a blister on the resident's left thigh and abdomen. The resident reported significant pain and had to alert the aide to stop the procedure. The aide acknowledged the error and reported the incident to a nurse, who observed the injury and provided pain medication. Facility policy and lesson plans explicitly state that direct care staff are not permitted to put fluids into a colostomy bag and should notify a supervisor if they encounter care needs beyond their scope. Interviews with facility leadership confirmed that the aide should not have performed the action and that the required competency for emptying an ostomy bag was documented as completed, despite the aide's lack of proper training. The incident resulted in a burn injury to the resident, with documentation of the wound and subsequent treatment.