Failure to Provide Ordered and Preferred Colostomy Care
Penalty
Summary
The facility failed to provide colostomy care as ordered and according to the resident's preferences for one resident who was alert, oriented, and dependent on staff for personal hygiene. The resident had a physician's order to have the colostomy bag emptied every shift, with documentation of the procedure and any changes in stool. The care plan, reflecting the resident's preference, specified that the colostomy pouch should be emptied, rinsed well with water, and reapplied, or replaced if not clean. However, review of CNA documentation showed multiple instances where there was no evidence that the colostomy pouch was emptied on various shifts and days. Interviews with the resident confirmed that the pouch was not emptied or cleaned as required, leading to discomfort and nausea due to the buildup of gas and fecal matter. Further interviews with staff revealed that CNAs only emptied the colostomy pouch when instructed by a nurse and typically did not follow the resident's preference for cleaning the pouch. Observations confirmed that the resident's colostomy pouch was often left more than half full and puffed up with gas. The Assistant Director of Nursing verified the lack of documentation and could not confirm that the required care was provided. These findings demonstrate a failure to ensure that colostomy care was consistently provided as ordered and per the resident's stated preferences.