Failure to Follow Physician Orders for Nephrostomy Tube Care
Penalty
Summary
Surveyors identified that the facility failed to provide nephrostomy care and services consistent with physician orders for one resident. Facility policy titled "Ostomy Care" dated 4/17/25 stated that ostomy care would be provided for residents with a urostomy, colostomy, or ileostomy to maintain peristomal skin integrity, monitor the stoma, manage odor, and promote self-esteem. Resident R1 was admitted on an unspecified date and had diagnoses including obstructive uropathy, other toxic encephalopathy, and muscle weakness. Physician orders dated 12/31/25 directed that the resident’s left nephrostomy tube be flushed daily in the morning with 10 mL normal saline solution (NSS) to keep the tube patent, and as needed, by an RN only. Review of the MAR/TAR for February 2026 showed that the ordered morning nephrostomy tube flushes were missed on three days (2/2/26, 2/5/26, and 2/6/26). The clinical record, including progress notes, did not contain any explanation for why the flushes were not administered as ordered, nor any documentation that staff attempted to complete the flushes later in the day if they were not done in the morning. During an interview on 2/24/26 at 3:06 p.m., the DON was informed that the facility had failed to provide nephrostomy care and services consistent with the physician’s orders for this resident, constituting noncompliance with 28 Pa. Code 211.10(c) and 211.12(d)(1)(2)(5).
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