Failure to Follow Physician Orders and Perform Timely Colostomy Care
Penalty
Summary
A deficiency occurred when the facility failed to ensure that physician orders were followed for medication administration and colostomy care, resulting in a resident not receiving timely intervention for a new stoma that became necrotic. The resident, who had a history of volvulus, heart failure, and chronic kidney disease, was admitted with a pink, patent, and protruding ostomy. Physician orders included medications such as Colace and polyethylene glycol for bowel management, as well as daily colostomy care and assessments. However, documentation revealed that the resident did not receive the ordered Colace, and there was no evidence that daily assessments of the colostomy site, stoma, and bowel sounds were performed as required. The resident experienced ongoing pain, nausea, and changes in condition, including a black, necrotic, and odorous stoma, which was not promptly addressed. Nursing notes indicated that the resident's condition deteriorated, with symptoms such as slurred speech, bleeding from the stoma, and abdominal distention. Despite these changes, there was a lack of comprehensive assessment and documentation, including vital signs, pain assessment, and bowel sound evaluation at critical times. Communication with the physician was delayed, and the facility did not demonstrate a sense of urgency in responding to the resident's declining condition. Further review showed that other residents also experienced lapses in daily skilled assessments, as required by facility policy. For example, another resident with multiple diagnoses did not have daily skilled notes or assessments completed for several days. Interviews with staff confirmed that assessments were expected but not consistently performed or documented. These failures contributed to the deficient practice of not providing appropriate treatment and care according to physician orders and resident needs.
Removal Plan
- Audit of current residents inhouse was performed to ensure stoma is patent and healthy appearing
- Stoma site will be evaluated daily with care on the treatment record
- DON/designee will provide education to all clinical staff on completion of colostomy care, evaluation, and documentation on the treatment record
- The Administrator/designee will be responsible for the implementation of the New Process
- The New Process/system will be started and no licensed staff will be able to return to work until they complete the above stated education