Failure to Provide Consistent Ostomy Care for Dependent Resident
Penalty
Summary
A deficiency occurred when a resident who was dependent on staff for colostomy management did not receive consistent ostomy care. The resident, admitted with diagnoses including colon cancer and a colostomy, was documented as requiring staff assistance for ostomy management according to the Minimum Data Set (MDS). The resident's care plan instructed nursing staff to keep the skin around the stoma clean and dry. However, during a review, it was found that the colostomy drainage bag had not been emptied during the overnight shift by the nurse on duty. On the following morning, a CNA discovered the resident with a full colostomy drainage bag that had burst, resulting in stool on the resident and the bed. The CNA alerted the nurse, who assessed the resident and found no skin excoriation. The nurse then cleaned the resident and notified the responsible party. When questioned, the overnight nurse admitted to forgetting to check on the resident due to being busy. The facility's policy emphasizes maintaining cleanliness and skin integrity for residents with ostomies, which was not followed in this instance.