Failure to Provide and Document Colostomy Care per Orders and Policy
Penalty
Summary
The facility failed to provide colostomy care in accordance with physician orders, professional standards, and the resident's comprehensive plan of care for one resident. The facility's policy required documentation of colostomy care, including the date and time care was provided, the name and title of the caregiver, any skin issues or signs of infection, how the resident tolerated the procedure, and notification of the supervisor for refusals or abnormal findings. For the resident in question, who had multiple diagnoses including Parkinson's Disease and a colostomy, the care plan and physician orders specified that the stoma site should be checked every shift for swelling and redness, and the colostomy bag changed as needed every shift. However, a review of the medical record, medication administration record (MAR), and nursing notes revealed no documentation that colostomy care was performed or that the stoma site was checked from June 28 to July 7. During this period, the resident was later transferred to the emergency department, where hospital records noted abnormal bowel color at the ostomy site and questionable gangrene, requiring surgical consultation. The facility's Director of Nursing confirmed the absence of documentation for the required colostomy care during the specified timeframe.