Baseline Care Plan Lacked Ostomy Care for Newly Admitted Resident
Penalty
Summary
The facility failed to ensure that a baseline care plan for a newly admitted resident included pertinent information regarding the resident's colostomy care needs. Upon review, it was found that the resident had diagnoses including diverticulitis of the large intestine with perforation and abscess, and had a newly acquired colostomy. Physician orders specified detailed ostomy care requirements, including changing the stoma wafer and bag on specific days, daily observation of the stoma for skin breakdown and circulation, and monitoring colostomy output for abnormalities. Despite these orders and the resident's condition, the baseline care plan did not mention the presence of a colostomy or include any focus on ostomy care. Interviews with the DON revealed that the initial admission assessment did not document the presence of a colostomy, and the baseline care plan was created based on this incomplete assessment. The facility's policy on colostomy/ileostomy care requires review of the care plan to assess for special needs, but this was not followed in this case. As a result, the resident's immediate health care needs related to the colostomy were not addressed in the baseline care plan within 48 hours of admission.