Failure to Address Colostomy-Related Behaviors and Mental Health Needs
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident diagnosed with mental disorders and psychosocial adjustment difficulties, specifically related to colostomy care and associated behaviors. The resident, who had diagnoses including depression, ADHD, and hemiplegia, was observed with a colostomy bag that was improperly positioned and ballooning. The resident reported that staff only emptied the colostomy bag when prompted and that he often managed the bag himself, which caused him anxiety. Despite physician orders for staff to perform colostomy care every shift and as needed, documentation showed inconsistent completion of these tasks, and staff interviews confirmed that the resident sometimes removed the colostomy bag and flange without notifying staff. Care plan reviews revealed that while the resident's depression and psychosocial well-being were addressed, there were no specific interventions related to the resident's colostomy behaviors or ADHD diagnosis. The care plans did not address the resident's repeated removal of the colostomy bag or provide strategies to manage these behaviors. Additionally, there was a lack of documentation regarding staff reminders to the resident about not unsealing the colostomy and no evidence of education provided to the resident about proper colostomy care or behavior management. Further, staff failed to notify the physician of the resident's severe depression score and did not document or communicate the resident's colostomy-related behaviors to the physician or in progress notes. Observations and interviews indicated that the resident's actions, such as emptying the colostomy bag on the facility floor, were not adequately addressed in care planning or staff interventions. The facility was unable to provide policies regarding behavior identification and tracking when requested.