Failure to Provide Appropriate Colostomy Supplies and Care
Penalty
Summary
The facility failed to provide appropriate colostomy supplies for a resident with a history of colon cancer, colostomy, and parastomal hernia, resulting in ongoing problems with ostomy management. The resident had a BIMS score indicating moderate cognitive impairment and a care plan goal that ostomy care would be managed appropriately and stool would not leak. A CNA reported that staff had been using urostomy bags on the resident’s colostomy site for months because the correct 38 mm colostomy pouches were not in stock, and only 28 mm colostomy pouches were available. During an observation of colostomy care, the resident’s transparent ostomy bag was nearly full of feces, with fecal matter leaking from the upper right portion of the stoma and a strong, noxious odor in the room. The CNA obtained a urostomy bag from the resident’s nightstand and demonstrated that the plastic had to be ripped to fit the resident’s stoma and that the bag contained an anti-reflux valve designed for urine, which the CNA stated became clogged with stool and led to backups and fecal leakage. The DON, who was responsible for ordering medical supplies, initially stated the clear pouches in use were colostomy bags and that the facility was working on obtaining opaque bags per the resident’s preference. However, when asked to oversee the colostomy care, the DON confirmed that the pouch in use was a urostomy bag and acknowledged that using a urostomy bag instead of a colostomy bag could restrict fecal flow and lead to backup, leakage, or infection. An inventory of the supply closet revealed only a partial box of 28 mm colostomy pouches, with no appropriate-sized colostomy bags available for the resident. The resident reported significant embarrassment related to the transparency of the pouch and the associated odors from leakage, stating that he had not previously experienced such issues with his colostomy and that he had requested a different type of pouch. He also reported that participation in religious services was very important to him but that he sat in the back and avoided socializing due to concerns about the appearance and smell of his colostomy bag.
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