Failure to Provide Timely Colostomy Care
Penalty
Summary
A deficiency occurred when staff failed to provide timely colostomy care to a resident with a history of rectal cancer and an ileostomy. The resident had physician orders for staff to empty the ostomy every shift and as needed, and to change the appliance weekly and as needed. Despite these orders, the resident reported that her colostomy bag burst open and, after activating her call light, a nurse entered the room, turned off the call light, and left without providing care. The resident remained covered in stool for at least two hours, ultimately calling a family member for assistance. The family member arrived to find the resident still soiled, took photographs, and cleaned her up before reporting the incident to the unit manager. The family member stated that similar issues had continued to occur. Observations confirmed the resident's colostomy bag was often not emptied or changed in a timely manner, with the bag being half full of liquid stool during one interview and the resident found covered in stool during another observation. Photographic evidence provided by the family member showed dried, liquid stool on the resident's gown and bedding, and the colostomy bag not attached to the abdomen. The Interim DON acknowledged awareness of frequent leaks but was unaware of the lack of timely emptying. These findings demonstrate a failure by staff to provide appropriate and timely ostomy care as required by the resident's care plan and physician orders.