Failure to Document and Order Urostomy Care for Resident
Penalty
Summary
The facility failed to provide proper urostomy care for a resident with a diagnosis of neurogenic bladder and a urostomy. Review of the facility's policy indicated that documentation of ostomy care should include the date and time care was provided, the name and title of the caregiver, any skin issues or signs of infection, the resident's tolerance of the procedure, refusals and interventions, and the signature of the person recording the data. However, the resident's clinical record did not contain documentation of urostomy care after March 23, 2025, and there was no physician order specifying the details of urostomy care. The care plan referenced care as ordered by the physician, skin nurse, or charge nurse, but lacked current, specific interventions or documentation. Interviews with the resident revealed that she independently performed her own urostomy care and was comfortable doing so. Staff interviews confirmed that the resident managed her own care and requested supplies as needed to maintain independence. Despite this, the DON acknowledged that there should have been a physician order detailing urostomy care and that the provision of care should have been documented in the clinical record, in accordance with facility policy and regulatory requirements.