Failure to Involve Resident in Person-Centered Care Planning for Colostomy Care
Penalty
Summary
The facility failed to offer a care conference to a resident with a colostomy, resulting in the resident's inability to participate in the development and implementation of his person-centered care plan. The resident's care plan did not include individualized instructions for colostomy care, such as the specific supplies required or the process for changing the colostomy bag. Documentation showed that the resident was cognitively intact and had diagnoses including Crohn's disease and a colostomy. The medication administration record indicated scheduled changes for the ostomy bag, but the resident reported a preference for morning changes, which was not accommodated. The resident also experienced multiple episodes of colostomy leakage during the initial weeks of his stay and had to repeatedly request the use of specific ostomy supplies he was familiar with, which were only provided after several weeks. Interviews with the resident, an LPN, and the DON confirmed that there was no documentation of a care conference in the resident's chart, and the DON was unaware if one had occurred. Facility policy required resident involvement in comprehensive person-centered care planning, with documentation if participation was not practicable. The lack of a care conference and individualized care planning for the resident's colostomy care constituted a failure to involve the resident in planning and implementing his care as required by facility policy and resident rights.