Failure to Provide and Document Colostomy Care
Penalty
Summary
The facility failed to provide and document appropriate colostomy care for a resident who had a colostomy. The resident, who was cognitively intact and admitted for wound care and rehabilitation, had a history of a laparoscopic diverting sigmoid colostomy and sacral debridement. Despite the presence of other medical orders, there was no physician order for colostomy care or documentation specifying the frequency and interventions for colostomy management. Review of the resident's medical records showed sporadic documentation of colostomy bag changes, with the last entry occurring nearly a month before the resident's discharge, and no records of colostomy care during the final weeks of the resident's stay. Interviews with facility leadership confirmed that the expectation was for colostomy care to be provided, monitored, and documented according to physician orders, which should have included details such as site monitoring, output, and bag change frequency. Both the ADON and DON acknowledged that there should have been a physician order and a care plan for colostomy care, and that daily documentation was expected while the resident was under skilled services. The lack of a physician order, care plan, and consistent documentation led to the identified deficiency in colostomy care for the resident.