Failure to Document and Provide Complete Colostomy Pouch Changes and Stoma Care
Penalty
Summary
The deficiency involves a failure to provide and document appropriate colostomy care and services for a resident with a history of rectal, rectosigmoid, and anal cancer who had undergone an abdominoperineal resection and had a colostomy. The resident was severely cognitively impaired and had both an indwelling catheter and an ostomy. The care plan, revised on 6/18/24, directed staff to monitor and record bowel movements by emptying the ostomy pouch, monitor and record the peri-stoma condition, and provide and maintain appropriate ostomy supplies. A physician’s order dated 2/26/26 required staff to check the colostomy pouch every shift for patency and, if full, to empty or change it every shift and as needed. The March 2026 MAR/TAR showed that the colostomy pouch was monitored every shift as ordered. However, the clinical record lacked documentation that the colostomy pouch was ever fully changed or that stoma care was provided, despite the resident’s ongoing need for ostomy management. During interviews, the DON was unable to provide information about the frequency of stoma care and complete bag changes, and the Administrator stated that the resident’s colostomy pouch was a one-piece system, with no separate wafer or pieces to change. The facility’s own policy on colostomy, urostomy, or ileostomy care required regular changing of the pouching system to avoid leaks and skin irritation, limiting removal to no more than once a day unless there was a problem, and cleaning and drying the skin around the stoma. The absence of documentation of full pouch changes and stoma care, in the context of these orders and policies, constituted the identified deficiency.
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