Failure to Provide Timely and Effective Ileostomy Care Resulting in Hospitalization
Penalty
Summary
The facility failed to provide appropriate ileostomy care and services for a resident who required such care, resulting in significant adverse outcomes. The resident, who had a complex medical history including Crohn's disease, severe malnutrition, schizophrenia, and recent ileostomy creation, was observed and reported to have repeated issues with the ileostomy wafer and bag not remaining in place. Staff documented and family members reported frequent leakage, overfilling, and delays in emptying and changing the ileostomy bag, leading to the resident being left in vomit and feces for extended periods. Photographic evidence and interviews confirmed that the resident was found covered in bodily waste, with towels and briefs used as makeshift measures to manage leakage, and the ostomy site left uncovered at times to allow the skin to dry. Multiple staff members, including LVNs and CNAs, described ongoing difficulties maintaining the ostomy system due to high output and poor wafer adhesion, with interventions such as using adhesive pastes, skin prep, and absorbent materials proving ineffective. Despite these challenges, the resident's care plan and physician orders required regular and as-needed ostomy care, including timely emptying and changing of the bag and wafer. Documentation and interviews revealed that staff became frustrated with the resident's needs, and there were delays and reluctance in providing necessary care, as well as poor communication and customer service. Family members repeatedly raised concerns about the resident being left in soiled conditions and the lack of prompt response from staff. As a result of these failures, the resident developed excoriation and skin breakdown around the stoma, experienced nausea, vomiting, and abdominal pain, and was ultimately transferred to the hospital. Upon hospital admission, the resident was diagnosed with sepsis, acute kidney injury (AKI), and abdominal wall cellulitis, with medical records and hospital staff attributing these conditions to inadequate ostomy maintenance and fecal contamination. The incident was identified as Immediate Jeopardy, and the facility's deficient practices placed not only this resident but also others with ostomies at risk for serious harm.