Failure to Provide Timely Colostomy Care Upon Resident Request
Penalty
Summary
A deficiency was identified when a resident who required colostomy care did not receive timely assistance with changing their colostomy bag upon request. The resident, who had a history of intestinal obstruction, dysphagia, cognitive communication deficit, and gastrostomy status, reported to a state surveyor that he wanted his colostomy bag changed because it had not been emptied since the previous night and was starting to lift, raising concerns about potential leakage. The resident used the call light, and a facility aide informed the nurse of the request. However, the bag was not changed promptly, and the resident stated that the bag had leaked on his clothes before, though he could not recall the exact timing. Further evidence was provided by a complainant who observed the resident in bed with a leaking colostomy bag that had stained his clothing. The complainant witnessed an aide inform the nurse, but it took over two hours for the nurse to respond and change the bag, after which the aide cleaned the resident. A photograph submitted by the complainant showed visible stains on the resident's clothing. Interviews with CNAs confirmed that only nurses were permitted to change colostomy bags and that there were repeated delays in fulfilling resident requests, sometimes lasting an entire shift. CNAs expressed concerns that such delays could lead to leaks, skin irritation, and dignity issues for the resident. A nurse confirmed that the resident had requested a bag change but stated she had only burped the bag and planned to change it after the resident ate lunch, claiming the bag was not full and there was no immediate risk. Both the DON and the administrator stated that residents have the right to have their colostomy bags changed upon request and acknowledged that delays could result in dignity issues and potential harm. The facility's policy on colostomy care was requested but not provided before the survey exit.