Failure to Provide Effective Colostomy Care Resulting in Repeated Leaks
Penalty
Summary
The facility failed to follow its colostomy care policy for two residents, resulting in repeated colostomy leaks. One cognitively intact male resident with a diagnosis including colostomy and UTI was observed on two consecutive days with a leaking colostomy bag, first on his return from the hospital and again the next day with a new bag leaking through the base dressing. A CNA stated she had not had a chance to check on him after his hospital return and that nurses were responsible for colostomy care, and another CNA confirmed the colostomy should not leak. A second male resident with severe cognitive impairment was observed with a leaking colostomy and a moderate amount of stool on his abdomen, and an LPN stated the colostomy had been changed that day, did not know who changed it, and acknowledged it should not leak. The nurse consultant confirmed that nurses are supposed to change colostomies and that they should not leak because this can cause skin irritation and infection. The facility’s colostomy care policy stated that the purpose of colostomy care is to prevent infection and skin irritation. These observations, staff interviews, and the facility’s own policy demonstrate that colostomy care was not consistently provided in a manner that prevented leakage for the two residents reviewed for colostomy care.
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