Failure to Develop Individualized Ostomy Care Plan
Penalty
Summary
A deficiency was identified when the facility failed to provide an individualized care plan for a resident with a urostomy. The resident, who was able to clearly express her needs, had her ostomy size changed following a medical appointment. After returning, she requested frequent changes of her ostomy supplies and refused to use her old supplies, as the new supplies for the updated size had run out. Staff, including the Administrator and DON, acknowledged that Medicare Part B would not cover premature reordering of supplies and that the resident was informed of her options, including going to the hospital, which she refused. Despite these ongoing issues and repeated requests from the resident, there was no care plan in place addressing her ostomy care needs. Upon review of the electronic health record, the DON confirmed that the care plan for ostomy care was missing, even though the resident's MDS assessment documented the presence of an ostomy and physician orders specified scheduled changes. The lack of a person-centered, individualized care plan for ostomy care was not in accordance with professional standards and guidelines, as required by CMS regulations. This omission was confirmed through record review and staff interviews.