Failure to Update Care Plan for Resident’s Colostomy-Related Behaviors
Penalty
Summary
The deficiency involves the facility’s failure to update a resident’s care plan after a documented change in condition related to colostomy care. A complaint alleged that nursing staff failed to provide adequate colostomy care to one resident. Medical record review showed the resident had physician orders for care and maintenance of a colostomy bag and stoma. A progress note dated 2/18/26 documented that the resident frequently manipulated and removed the colostomy bag, which required staff to change the bag frequently and resulted in irritation at the colostomy site. Despite this documented behavior and its effects, review of the resident’s care plan showed no evidence that the behavior of manipulating or removing the colostomy bag and stoma was included, and no interventions were listed to address or prevent this behavior. During an interview, the DON confirmed that the resident frequently removed the colostomy bag and did not understand how to reattach it independently, and the surveyor identified that these behaviors and related interventions were not reflected in the resident’s care plan.
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