F0691

D

Failure to Provide and Document Colostomy Care

Westland, Michigan Survey Completed on 01-29-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide and document colostomy care for a resident with a known colostomy. The resident, who had a colostomy in the left lower abdomen and diagnoses including Colostomy Status and Diverticulitis of the large intestine, reported that staff sometimes forgot to empty the colostomy bag and only did so when reminded. The resident described an instance when the colostomy bag became so full that staff had to make two trips to empty it and were surprised it had not burst. The resident’s Minimum Data Set showed impaired cognition with a Brief Interview for Mental Status score of 11/15, and the resident required staff assistance with bed mobility and transfers.

Record review showed that upon admission there were no physician orders related to colostomy care and no documentation of colostomy care on the Treatment Administration Record. The Unit Manager stated that admitting nurses are expected to enter orders for needs such as colostomy care and that chart audits are used to identify and correct missing orders. The DON reported being unsure why colostomy care orders were not entered at admission and indicated that unit managers double-check new admission orders. Review of the facility’s colostomy policy showed it did not address colostomy care.