F0691

D

Failure to Provide and Document Colostomy Care and Orders

Dubois, Pennsylvania Survey Completed on 02-06-2026

Penalty

No penalty information released

Summary

The facility failed to provide ordered and documented colostomy care for a resident who was cognitively impaired, required staff assistance for daily care, had a diagnosis of sepsis, and was admitted with a colostomy. The facility’s colostomy care policy required care per physician orders to provide good skin care and monitor the stoma and surrounding skin, but review of the clinical record showed that from the date of admission with a colostomy until the resident was sent to the hospital, there was no documentation that the ostomy appliance had been changed or that colostomy care was provided. After the resident was readmitted, there was again no documentation of ostomy appliance changes or colostomy care for an extended period. In addition, there were no physician orders in the record for changing or emptying the colostomy appliance, and the DON confirmed that there were no ostomy orders and no documented evidence that colostomy care was being provided.

This lack of physician orders and absence of documented colostomy care for the resident’s ostomy appliance constituted the deficiency identified by surveyors under 28 Pa. Code 211.12(d)(5) Nursing Services.