Failure to Provide Ordered Ostomy Care and Staff Awareness for Resident With Ileostomy
Penalty
Summary
The deficiency involves the facility’s failure to provide ostomy care and obtain physician orders for a resident with an ileostomy, contrary to its own policy requiring licensed nurses to provide ostomy care under physician orders specifying type of ostomy, frequency of pouch changes, and equipment. The resident’s admission MDS documented moderately impaired cognition, diagnoses including Crohn’s disease, ileostomy status, chronic kidney disease, major depressive disorder, and anxiety, and the presence of an ostomy appliance. However, review of the physician order summary showed no orders for ostomy care, and the medical record contained no baseline or comprehensive care plan addressing ostomy care needs. During interview, the resident reported feeling shaky and unwell and was unable to answer specific questions about medical needs. A family member reported that family had been coming in to assist with ostomy care because staff were not helping the resident empty the ostomy bag, resulting in the resident waiting for family assistance, and stated that concerns had been reported to a DON without any response. Staff interviews further demonstrated lack of awareness and direction regarding the resident’s ostomy. One LPN described responding to a loud noise from the resident’s room and finding the resident on the floor after an unwitnessed fall, with feces covering the floor and the resident holding the ostomy bag to prevent further leakage; the resident stated they had been trying to walk to the bathroom to empty the bag. The resident was sent to the hospital for shoulder pain and altered cognitive status. That LPN, as well as another LPN, both stated they were unaware the resident had an ostomy bag and confirmed there were no physician orders for ostomy care or information on whether the resident could manage the ostomy independently. The DON later stated an expectation that staff assist with ostomy care, be informed of the ostomy’s presence, have a care plan with ostomy interventions, have physician orders for ostomy care, and that concerns reported by family be addressed, underscoring that these expectations were not met in this case.
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