Failure to Document and Perform Colostomy Bag Changes per Physician Orders
Penalty
Summary
The facility failed to ensure that colostomy drainage bag changes were completed according to physician orders for a resident with a colostomy. The physician's order specified that the ostomy bag should be changed every three days and as needed. However, a review of the treatment administration record over a specified period revealed no documentation that these changes had been performed as ordered. The resident, who had diagnoses including surgical aftercare, colostomy status, pulmonary embolism, and malignant neoplasm of the colon, reported that her colostomy bag had burst a couple of times when she rolled over in bed, and she was unsure how often staff were changing the bag. Further investigation found that the order to change the colostomy bag appeared on the treatment administration record but was not entered correctly, preventing staff from documenting when the changes were completed. Interviews with facility leadership confirmed the lack of documentation for the required colostomy bag changes. Additionally, facility policy required staff to document the date and time of colostomy care, but this was not done in this case.