Failure to Develop Comprehensive Ostomy Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan addressing all aspects of ostomy care for a resident with a colostomy. The care plan in place did not include specific interventions for monitoring signs and symptoms of infection, leakage, or instructions on cleaning the stoma and peristomal skin. Documentation showed that the resident required assistance with ostomy care, and staff interviews revealed that some staff were not fully aware of the necessary procedures or were slow to respond, resulting in an incident where the ostomy bag leaked and caused irritation to the resident's stoma. Staff interviews confirmed that certified nursing assistants (CNAs) and nurses were expected to review the care plan and report any concerns related to ostomy care, but the care plan lacked detailed interventions. The resident, who was cognitively intact, expressed concerns about infection and leakage, and staff acknowledged that the care plan did not adequately address these needs. The Director of Nursing and the nurse case manager both reviewed the care plan and recognized the deficiencies in the interventions related to ostomy care.