Failure to Document Colostomy Appliance Changes
Penalty
Summary
The facility failed to document colostomy care for one resident with a history of severe cognitive impairment and multiple diagnoses, including colostomy status. The resident had an open-ended physician's order for colostomy appliance changes as needed, but the clinical record did not contain documentation of any appliance changes for several months. Interviews with nursing staff confirmed that the colostomy appliance was changed frequently, and aides documented the presence and amount of stool in the appliance each shift, but there was no record of the actual appliance changes in the clinical record. Observation of the resident's colostomy showed it was clean and free of infection at the time of survey. The Assistant Director of Nursing stated that colostomy care was performed daily and the appliance should be changed every three days, in accordance with facility policy. However, the required documentation of colostomy care and appliance changes was missing from the resident's clinical record, which did not align with accepted professional standards or the facility's own policy.