Failure to Ensure Safe Discharge and Adequate Preparation for Colostomy Care
Penalty
Summary
The facility failed to ensure a safe and appropriate discharge for a resident who required ongoing care for a new colostomy following abdominal surgery. The resident was admitted for subacute rehabilitation after surgery and had limited family support, living alone with only one relative nearby who was unable to provide daily assistance. Despite clear hospital discharge instructions for a surgical follow-up within 10-14 days, the facility did not schedule the necessary appointment for staple removal or arrange for adequate post-discharge support. The resident was discharged home while still requiring supervision or assistance for activities of daily living, including colostomy care, transfers, and ambulation, as documented by therapy assessments. Multiple staff interviews and medical record reviews revealed that the resident expressed concerns about her ability to manage colostomy care independently at home. Nursing and therapy staff noted that the resident was not able to perform all aspects of colostomy care without significant cues and was not at her functional baseline for mobility, with an increased fall risk. The resident and her family both reported feeling unprepared for discharge, and the resident was only provided with a single colostomy care education session, which was insufficient for her to achieve independence in this area. The facility's social services director confirmed that only limited home health services were arranged, and not all necessary follow-up appointments were scheduled. Following discharge, the resident required repeated emergency room visits due to complications related to her colostomy, including staple removal, wound infection, and inability to manage the colostomy appliance. Emergency department documentation and provider notes indicated that the resident was unable to care for her colostomy, experienced leakage and skin issues, and was not safe to be living independently. The facility's failure to ensure the resident was adequately prepared and supported for discharge resulted in repeated hospitalizations and ongoing health complications.