F0880

D

Failure to Follow Colostomy and Catheter Care Policies

Richton Park, Illinois Survey Completed on 02-24-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow its own policies for colostomy care and indwelling catheter management for two residents. One cognitively intact male resident with a colostomy, suprapubic catheter, and recent UTI was observed in an isolation room with his urinary catheter bag placed in the bed rather than kept below bladder level. Shortly after his return from the hospital, his colostomy bag was observed leaking, with the insertion site resealed using additional tape, and a dirty, soaked, loose dressing was noted at the suprapubic catheter site beneath the colostomy bag. The resident reported having recently been hospitalized twice due to feeling very ill and stated that the colostomy bag was leaking onto his catheter site. A CNA reported she had not yet checked on him after his readmission, and the DON later stated that nurses are expected to check residents immediately upon readmission and ensure all tubing and drains are safely positioned. The resident’s POS showed he was receiving IV Meropenem for a UTI.

A second male resident with severe cognitive impairment was observed in bed with a leaking colostomy and a moderate amount of stool on his abdomen. An LPN stated the colostomy had been changed that day but did not know who changed it and acknowledged it should not be leaking. A nurse consultant confirmed that nurses are responsible for changing colostomies and that they should not leak, as well as reiterating that urinary catheter bags should be maintained below bladder level. The facility’s colostomy care policy stated that the purpose of colostomy care is to prevent infection and skin irritation, and its catheter care guidelines specified that urinary drainage bags must always be kept below bladder level, but these practices were not followed for the two residents observed.