Failure to Provide Timely Colostomy Care and Response to Resident Requests
Penalty
Summary
The facility failed to provide necessary colostomy care for a dependent resident who required assistance with emptying her colostomy bag. The resident, who had diagnoses including irritable bowel syndrome and an encounter for a colostomy, had a care plan dated 10/20/2023 that required colostomy care every shift and as needed. On the evening of 2/1/2026, the resident activated her call light around 8:00 p.m. and requested that an agency CNA empty her colostomy bag. The CNA stated she did not feel comfortable performing the task. The resident then asked the CNA to inform the nurse because the colostomy bag was filling up. After approximately 30 minutes, the resident again used the call light; the same CNA returned and reported she had asked other CNAs, but not the nurse, and said she would ask the nurse. The resident subsequently called the front desk multiple times requesting to speak with a supervisor. The AM receptionist stated that when residents call the front desk, she overhead pages the supervisor or nurse to the room. However, the PM receptionist reported that on the night in question, she transferred the resident’s calls to the voicemail of the unit manager and house supervisor and did not overhead page. The unit manager and DON both stated they expected the receptionist to overhead page and the CNA staff, including agency staff, to notify the nurse when there is a skill-related issue or when a resident requests to see the nurse. The executive director stated the resident should not have had to call 911 for assistance. When emergency services arrived, the agency nurse entered the room with medications and was unaware the resident needed colostomy care, at which point the resident’s colostomy bag was leaking feces. The facility’s colostomy care policy dated 6/30/2025 required that ostomy appliances be emptied every shift and as needed.
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