Failure to Maintain Resident Dignity and Hygiene Due to Unaddressed Colostomy Leak
Penalty
Summary
A resident with a history of hemiplegia, hemiparesis, major depressive disorder, and cognitive communication deficit was observed sitting in a hallway in a wheelchair for approximately 45 minutes with a visibly leaking colostomy bag. The resident's t-shirt and sweatpants were soiled with a brown liquid substance consistent with bowel movement, and there was a foul odor present. Multiple staff members walked past the resident during this time without providing assistance or addressing the resident's hygiene needs. The resident was unable to move himself or communicate his needs effectively due to his medical conditions. The resident's care plan documented the need for staff to provide care to the colostomy site every shift and as needed, and to ensure the resident was clean, well-groomed, and appropriately dressed. Despite these directives, staff failed to recognize and respond to the resident's condition in a timely and dignified manner. Staff interviews confirmed that the resident was left in the hallway as a reminder to get him into bed after breakfast, but his hygiene needs were not addressed during the observed period. Facility policy required the provision of a safe, clean, and comfortable environment with person-centered care, which was not upheld in this instance.