Failure to Provide Dignified and Timely Ostomy Care, and Maintain Resident Dignity
Penalty
Summary
The facility failed to provide care that maintained the dignity and quality of life for several residents, particularly a male resident with a recent ileostomy. Despite clear orders for regular ostomy care, staff did not consistently empty the resident's ileostomy bag in a timely manner, resulting in repeated leakage of bowel contents onto the resident and his bedding. On multiple occasions, the resident was left soiled for extended periods, and staff struggled to keep the ostomy system intact, with some resorting to using towels and briefs to absorb leakage rather than promptly replacing the ostomy appliance. Documentation and interviews confirm that the resident was found with a full, leaking ileostomy bag on several shifts, and family members had to repeatedly request staff intervention. Staff interactions with the resident and his family were unprofessional and lacked respect. Interviews revealed that a nurse and a CNA debated in front of the resident and his family about who would provide care, and the nurse made dismissive comments about having to "deal with" the resident. The resident and family reported that staff expressed disgust while providing care and accused the resident of causing the leakage, which he denied. The resident, who was cognitively intact, reported feeling neglected and stated that his call light was not answered promptly when he needed assistance with his ostomy care. Additionally, the facility failed to ensure that staff were adequately trained in ostomy care and did not promptly notify the resident's physician of significant changes in his condition, such as persistent leakage, vomiting, and the presence of bowel movements from the rectum despite the ileostomy. When the resident was eventually sent to the hospital, he was transported while still soiled with vomit and feces. The facility also failed to ensure that staff knocked and announced themselves before entering the shared room of two other residents, further compromising resident dignity.