Failure to Provide Required Colostomy Care and Documentation
Penalty
Summary
A deficiency was identified regarding the care of a resident with a colostomy. The resident, who had diagnoses including intellectual disabilities, urinary incontinence, and colostomy status, had a physician's order for colostomy care every shift, but the order lacked specific directions. Additionally, there was no documented order for changing the colostomy bag and wafer, including the size. The resident's care plan required assessment of the stoma and surrounding tissue every shift for signs of skin impairment, such as redness, irritation, drainage, and bleeding. Upon review of the clinical record, there was no evidence that the stoma and surrounding skin were assessed every shift as required by the care plan. Interviews with the resident and the DON revealed that staff changed the colostomy bag only as needed, typically once a week or if it was leaking, rather than following the prescribed schedule. The DON confirmed that the facility failed to ensure appropriate treatments and services were provided for the use of a colostomy for this resident.