Failure to Establish and Implement Urostomy/Nephrostomy Care Orders
Penalty
Summary
The deficiency involves the facility’s failure to provide urostomy and nephrostomy tube care consistent with professional standards of practice for one resident who required such services. The resident was admitted with multiple significant diagnoses, including sepsis, acute osteomyelitis, COPD, chronic kidney disease, artificial openings of the urinary tract, female genital tract fistula, history of malignant neoplasm of the large intestine, colostomy status, and DVT. Admission documentation (the Medicaid 3008 form) identified the presence of a urostomy, bilateral nephrostomy tubes, and a colostomy. However, the facility’s admission/readmission data collection only documented a colostomy under gastrointestinal status and did not document the presence of a urostomy or nephrostomy tubes under genitourinary status. The resident’s MDS admission assessment did identify nephrostomy tubes and ostomies (including urostomy and colostomy), and subsequent NP and physician progress notes documented that the resident had a permanent colostomy, ileal conduit urostomy, and bilateral nephrostomy tubes, with all appliances intact on exam. These notes directed staff to continue daily assessment for leakage, obstruction, decreased output, skin breakdown, hematuria, foul odor, catheter-related pain, and signs of infection, and to maintain meticulous stoma and nephrostomy care. The resident’s care plan also referenced skin excoriation on the sacrum and coccyx related to an ileal conduit, ostomy, and nephrostomy tubes. Despite this, the physician orders in the record only contained a detailed order for colostomy appliance changes and associated skin care, with no corresponding orders for urostomy or nephrostomy tube care. During interviews, the DON stated that at admission, batch or standing orders are generated based on hospital discharge orders and that nurses are expected to reconcile hospital discharge orders with the physician, with all orders entered into the electronic medical record. The DON acknowledged that at the time of this resident’s admission, the orders should have addressed urostomy and nephrostomy tube care but could not explain the missing orders. Staff reported that ostomy care is to be provided every shift and as needed, with care orders reflected on the TAR and documented there, and that nurses follow physician orders when caring for residents with ostomies. Facility policies required individualized care plans, monitoring of treatment effectiveness, and incorporation of identified needs (such as ostomies and nephrostomy tubes) into the care plan and CNA Kardex. The lack of specific physician orders and corresponding TAR entries for urostomy and nephrostomy care, despite clear documentation of these devices in assessments and progress notes, led to the cited deficiency.
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