Failure to Provide Physician-Ordered Ileostomy Supplies
Penalty
Summary
Staff failed to provide proper ileostomy care for a resident who required such services. The facility's policy required staff to review the resident's care plan and assess for any special needs, and the physician's orders specified the use of particular ileostomy supplies, including specific brands and types of barriers, pouches, and accessories. However, observations revealed that the resident's ileostomy pouch was leaking, and the resident reported frequent leakage and multiple changes in a single day since returning from the hospital. The supplies in use did not match the physician's orders, as the facility only stocked a single type of ileostomy product for all residents, regardless of individual needs or orders. Interviews with nursing staff and the DON confirmed that the correct, physician-ordered supplies were not being used for the resident's ileostomy care. The failure to provide the ordered supplies resulted in ongoing leakage issues for the resident, contrary to both the care plan and physician's instructions. This deficiency was identified through review of policies, clinical records, direct observation, and staff interviews.