Failure to Complete Baseline Care Plan for Colostomy Care
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a resident who required specialized care, specifically for a colostomy. The resident, a female with multiple complex diagnoses including type 2 diabetes, bilateral above-knee amputations, stage III pressure ulcer, and peripheral vascular disease, was admitted with orders for colostomy care. Despite these needs, the baseline care plan was not completed to reflect her colostomy and the required monitoring and care instructions. The resident's electronic medical record and active orders indicated the necessity for colostomy bag checks and changes, but this was not incorporated into her baseline or comprehensive care plans. Observations and interviews revealed that the resident was experiencing pain and had a colostomy bag in place, with care being provided by nursing staff as needed. However, the Director of Nursing acknowledged that the baseline care plan was opened but not completed, and that the omission of colostomy care instructions could result in missed care. Nursing staff were aware of the resident's colostomy and provided care, but were not informed that the baseline care plan was incomplete. Facility policy required a baseline care plan to be developed within 48 hours of admission to address immediate health and safety needs, but this was not followed in this case.