Failure to Ensure Physician Orders and Documentation for Colostomy Care
Penalty
Summary
The facility failed to provide appropriate colostomy care and services consistent with professional standards for a resident with a colostomy. Review of the resident's care plan confirmed the presence of a colostomy, but there were no corresponding physician orders or directives for colostomy care, appliance changes, or monitoring in the resident's records, including the Medication Administration Record (MAR) and Treatment Administration Record (TAR). Multiple staff interviews confirmed that there should have been specific orders for colostomy care, but none were present for the resident in question. Observations showed the resident had a colostomy bag in place, and staff described the expected procedures for colostomy care, including emptying and changing the bag and monitoring the site. However, both nursing and management staff acknowledged during interviews and record reviews that the required orders and documentation were missing. The facility's own policy required documentation of ostomy care tasks and matching physician orders, which were not found in the resident's records.