Failure to Promptly Address and Resolve Grievance Regarding Ileostomy Care
Penalty
Summary
The facility failed to ensure prompt resolution of a grievance related to improper ileostomy care for one resident. The resident, who had diagnoses including Type 2 Diabetes Mellitus, moderate protein-calorie malnutrition, gastrostomy and ileostomy status, and dementia, required partial to moderate assistance with activities of daily living. The resident's care plan included specific interventions for ileostomy care, such as scheduled appliance changes. The resident's responsible party reported to the DON on multiple occasions that the resident's ileostomy bag was leaking, resulting in feces on the resident and towels being used to catch the leakage. Despite these complaints, the responsible party stated that the issue persisted and was not resolved as assured by the DON. Review of facility records showed that no formal grievance was initiated for this resident, and the grievance log did not contain any entries related to the reported concerns. Documentation from the facility's Hand in Hand Program indicated that concerns about the timeliness of colostomy bag changes were noted and that nursing leadership was notified, but there was no follow-up or resolution documented. Interviews with staff confirmed that complaints from the responsible party were communicated to nursing leadership but were not processed as formal grievances, and no investigation or resolution was documented as required by facility policy.