Failure to Monitor and Document Colostomy Output
Penalty
Summary
The deficiency involves the facility’s failure to monitor and document bowel movements for a resident with a colostomy as required by the care plan and facility policy. The resident’s EMR documented diagnoses of colostomy and intestinal obstruction, and the admission MDS showed intact cognition with a BIMS score of 15. The resident’s care plan, initiated for dehydration or potential fluid deficit related to diuretic use, directed staff to monitor and document bowel sounds and the frequency of bowel movements. However, progress notes lacked any documentation of bowel movement monitoring, and the task documentation indicated continence was not rated due to the colostomy, with no recorded amount, frequency, or consistency of stool. During observation, a CNA was seen emptying the resident’s colostomy bag into a plastic trash bag and discarding it without any measurement or documentation of the stool. The CNA stated that staff did not monitor or document the frequency, amount, or consistency of the resident’s bowel movements and did not report this information to the nurse, although the CNA noted the stool was loose. A nurse confirmed that while night shift runs a bowel movement report for residents to check for constipation, staff did not document or monitor this resident’s bowel movements. An administrative nurse stated she expected staff to document and monitor the resident’s bowel movements, and the facility’s ostomy care policy required stool output, consistency, and color to be documented in the chart every shift, which was not done for this resident.
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