F0842

D

Failure to Document Assessments for New Colostomy and Abdominal Incision

Sparta, North Carolina Survey Completed on 03-19-2026

Penalty

No penalty information released

Summary

The facility failed to maintain a complete and accurate medical record for a resident admitted after an exploratory laparotomy with creation of a new colostomy. From admission to discharge, the resident’s chart contained no documented assessments of the abdominal incision or the new colostomy. Multiple nurses, the DON, and the Regional Nurse Consultant all acknowledged that assessments should be documented every shift for new admissions, particularly related to the reason for admission, yet no such documentation existed for this resident during the entire stay.

Nurse #1 reported assessing the resident’s new colostomy and abdominal incision, describing a damp gauze packed in the bottom of the incision with a dry gauze over it, but admitted she did not document her assessment, intending to do so later and then forgetting after the resident was discharged. Nurse #2 stated that assessments should be documented every shift and recalled the resident had a colostomy, but when informed there was no assessment documented, she could not confirm whether she had assessed the colostomy or incision and said she would need to refer to the record. Nurse #3 stated she assessed the colostomy, which was almost full with a good seal, and also assessed the abdominal incision, but when shown there was no documentation, she acknowledged she must have forgotten to chart it. The DON stated she also looked at the resident’s colostomy and incision but did not document her assessment and did not follow up with nurses when she later noted the absence of documentation. The Regional Nurse Consultant confirmed there were no documented assessments of the colostomy or incision, and the Physician Assistant stated he relies on nurses’ assessments in the medical record for treatment planning, underscoring the absence of required documentation.