Failure to Follow Physician Orders and Document Abdominal Fistula Care
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders and to involve the physician in treatment changes for a resident with an abdominal fistula, as well as the failure to care plan this condition. The resident had diagnoses including respiratory failure and hypertension and was admitted with an abdominal fistula covered by a colostomy bag. Physician orders in January 2026 directed specific abdominal fistula care, including cleansing the abdomen and fistula site, applying zinc oxide mixed with A&D ointment, and covering the fistula with a panty liner or exu-dry under a brief, with aides permitted to perform the care once trained. These orders were active and signed off on the TAR as completed every shift. Earlier in January, there had also been an order for use of an ostomy device and belt over the fistula, which was later discontinued. Despite these orders, the resident’s care plan did not include any focus area or interventions related to abdominal fistula care. Clinical record review showed multiple Health Status notes over several days documenting that the resident’s abdominal fistula was covered with a colostomy bag or colostomy appliance, and that new colostomy pouches were applied and checked frequently. These notes indicated that a colostomy bag was in use on multiple dates, even though there was no current physician order in place at that time for a colostomy bag, and the active order instead described a different fistula care method using zinc oxide and a panty liner or exu-dry. Interviews with the DON and the wound nurse confirmed that nurse aides had received verbal and hands-on training to perform the ordered abdominal fistula care and were providing the treatment, but there was no clear place in the record for them to document when this care was completed. The DON stated that aides would have documented under a bowel and bladder task, but the specific treatment was not an available option, and aides could not document in the TAR. The wound nurse explained that the resident was admitted with a colostomy bag that did not stay on, leading staff to try different methods and to apply whatever worked best at the time, including colostomy appliances without a current order. Both the DON and the wound nurse acknowledged there was no documentation to show when ostomy bags were applied and no task in the record to indicate completion of fistula care, resulting in a lack of adherence to physician orders and inadequate documentation of the resident’s abdominal fistula treatment.
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