Failure to Provide Timely Ostomy Care and Accurate Skin Assessment
Penalty
Summary
The facility failed to provide timely and appropriate care for a resident with an ileostomy, specifically by not cleaning and emptying the resident's ileostomy bag in a timely manner and failing to conduct an accurate skin assessment upon admission. The resident was admitted from the hospital with a recent surgical history, including a transverse incision in the right lower quadrant. On the day of the incident, staff were alerted multiple times by both physical therapy and the resident's family member that the ileostomy bag was soiled and overflowing. The Certified Nursing Assistant (CNA) delayed responding to the request, taking approximately 15-20 minutes to gather supplies and begin care after being notified. During care, it was observed that the ileostomy bag was overfilled, and the resident was left soiled for an extended period, as documented by the family member's email stating the resident waited an hour and a half to be changed. During the process of providing care, staff discovered a previously undocumented surgical wound on the resident's right lower abdomen, hidden under a skin fold. The wound was not visible unless the skin fold was lifted and was not documented in the initial skin assessment performed upon admission. The wound began leaking fluid mixed with blood, prompting further assessment by the Director of Nursing (DON), who confirmed the presence of a clean surgical slit with no sutures or ripped edges. The wound was only discovered after it began leaking, and its presence had not been communicated or documented by the admitting nurse, whose handwriting on the initial assessment was also noted to be illegible. The facility's policy on colostomy/ileostomy care requires review of the resident's care plan and assessment of special needs, but the failure to document the surgical wound and the delay in responding to the resident's hygiene needs resulted in deficiencies in care. The incident involved multiple staff members, including a Registered Nurse (RN), CNA, and DON, and was corroborated by interviews, record reviews, and family member communication. The resident's condition at the time included a recent surgical procedure, an ileostomy, and the presence of skin folds that obscured the surgical wound.