Failure to Follow Physician Order for Urostomy Bag Changes
Penalty
Summary
The deficiency involves the facility’s failure to provide urostomy care in accordance with physician orders and facility policy for one resident. The facility’s medication administration policy required that treatments be administered in accordance with physician orders, including required time frames. The resident was admitted with a history of urinary tract infections and an artificial opening of the urinary tract (urostomy). The Treatment Administration Record for January 2026 showed a physician’s order for the resident’s urostomy bag to be changed every Wednesday and Saturday, but there was no documentation that the bag was changed on Saturday 1/3/26, indicating the order was not followed. Interviews with staff revealed confusion and inconsistency regarding the storage and availability of urostomy supplies. A licensed nurse reported that urostomy bags had been moved multiple times—from the medication room, to the resident’s drawer, and then to central supply—and that at one point nursing staff believed they were out of bags before later finding them in the resident’s drawer. The central supply lead stated that urostomy bags were stored in central supply and that nurses could obtain them from a local hospital if the facility ran out. The DON confirmed that urostomy bags were kept in central supply or on the treatment cart and acknowledged that the resident’s urostomy bag should have been changed as ordered. The report states that this failure had the potential to cause infection.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.