Failure to Reactivate and Document Colostomy Care Orders After Resident Readmission
Penalty
Summary
The facility failed to provide colostomy care in accordance with professional standards and its own policies for a resident with a colostomy. Upon the resident's readmission from the hospital, physician orders for ostomy care, including changing the ostomy bag every three days, cleansing the area every shift, and emptying the bag every shift, were not reactivated. As a result, there were no active orders or documentation of ostomy care provided from the time of readmission until the orders were reinstated over three weeks later. During this period, nursing staff did not document the provision of colostomy or ileostomy care as required by facility policy. Interviews with nursing staff and administration confirmed that care may have been provided, but it was not consistently documented, and some staff admitted to not always recording the care they performed. The lack of documentation meant that there was no way to verify if the resident received the necessary ostomy care or if any issues were identified and addressed. The resident involved had a complex medical history, including colostomy status, hepatic encephalopathy, congestive heart failure, and end-stage renal disease. The resident was cognitively intact and did not refuse care. Facility records and staff interviews confirmed that the failure to reactivate orders and document care was contrary to both the facility's colostomy/ileostomy care policy and its charting and documentation policy, which require all treatments and services to be recorded in the medical record.