Repeated Nephrostomy Tube Complications Due to Inadequate Care and Staff Training
Summary
A deficiency was identified when a resident with bilateral nephrostomy tubes experienced repeated complications, resulting in six transfers to the emergency department within a 120-day period. The resident, who is cognitively intact and has multiple comorbidities including neuromuscular bladder dysfunction and diabetic nephropathy, required specialized care for nephrostomy tubes. The care plan included interventions such as the use of an abdominal binder, regular assessment and documentation of drainage, monitoring for infection, and catheter care. However, the care plan also contained outdated interventions that were not relevant to the resident's current needs, such as references to a Foley catheter and voiding trials. Despite the care plan, the resident experienced multiple incidents of nephrostomy tube dislodgement, malfunction, and infection. Documentation revealed that tubes were frequently pulled out during transfers, particularly with the use of a Hoyer lift, and that staff sometimes improvised solutions, such as attaching a Foley catheter to the nephrostomy tube. The resident also developed infections requiring hospitalization and intravenous antibiotics. Interviews with staff and the resident indicated inconsistent use of the abdominal binder, with the resident discontinuing its use due to a rash, and staff not being fully aware of this change. Training for staff on nephrostomy tube care and safe transfer techniques was limited to verbal discussions and occasional meetings, with no formal competency assessment documented in the facility assessment. Surveyor interviews further revealed that staff had only minimal training on nephrostomy tube care, and that interventions to prevent tube dislodgement were not consistently implemented or updated based on the resident's feedback and clinical needs. The facility's failure to ensure staff competency, update care plans appropriately, and consistently implement interventions led to repeated medical interventions and hospitalizations for the resident.
Penalty
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A resident with paraplegia and a documented colostomy required staff assistance to manage a colostomy and urinary catheter, and the MDS and care plan identified an ostomy with interventions for ostomy care as needed. Despite this, the monthly Physician’s Order Summary contained no orders for colostomy care, and there was no documentation of colostomy bag changes or stoma care. During interview, the DON could not provide further information, and these omissions occurred despite a facility policy requiring ostomy services to meet professional standards of quality.
A resident with cognitive impairment, intellectual disabilities, and an ostomy did not receive colostomy care in accordance with facility policy and professional standards. The facility’s policy required colostomy care per physician orders, including attention to stoma and peristomal skin. However, the resident’s clinical record lacked physician orders specifying the colostomy size and instructions for changing the colostomy appliance, and there was no documentation that the appliance was being changed. The NHA confirmed the absence of these orders and documentation, resulting in a deficiency related to colostomy care.
Two residents with colostomies did not receive care in accordance with facility policy and physician/family directives. For one resident, an LPN failed to date the colostomy bag as ordered to be changed and dated every three days. For another resident, an RN prepared and cut an ostomy wafer at the med cart without measuring the stoma, applied a wafer that was visibly too large, and stated she "just eyeballs" the size instead of using a measuring guide, despite facility policy requiring stoma measurement and cutting the wafer to fit.
Failure to Care Plan for Colostomy Management: The facility failed to develop care plans for the care and management of a colostomy for two residents. Both residents had an ostomy noted on the MDS and physician orders for weekly and PRN colostomy appliance changes, but their current care plans did not include colostomy care. The RNAC confirmed the omission during interview.
A resident with a left abdominal colostomy, partial intestinal obstruction, and CKD required assistance with hygiene and toileting and had physician orders for colostomy care and as-needed emptying of the colostomy bag. Over a multi-week period, the TAR and electronic record contained no entries showing that colostomy care or colostomy bag changes were provided, despite a care plan directing appliance changes per orders. Nursing staff acknowledged that, per facility protocol and the colostomy/ileostomy care policy, such care should include assessment of the stoma and surrounding skin, cleaning, and emptying or changing the bag, and must be documented with date, time, staff identification, skin findings, resident tolerance, and any refusals, but this documentation was absent.
A resident with paraplegia, urinary retention, and a right lower abdominal urostomy was allowed to perform self-catheterization without a physician order, competency assessment, or care plan, contrary to facility policy. Staff acknowledged they had never observed or assisted with the resident’s urostomy care and were unaware of the peristomal skin condition. From admission for several days, there was no urostomy care order, no documented assessment of the resident’s ability to self-catheterize, no records of catheterization frequency, and no monitoring or documentation of intake/output, urine characteristics, or stoma/skin condition as required by the facility’s urostomy and self-catheterization P&Ps.
Failure to Provide and Document Ordered Colostomy Care
Penalty
Summary
The deficiency involves the facility’s failure to provide and document appropriate colostomy care and services for a resident with a colostomy. The resident, who was cognitively intact and had diagnoses including paraplegia and colostomy status, reported needing staff assistance to manage her colostomy and urinary catheter. A recent MDS assessment documented that the resident had an indwelling catheter and an ostomy, and the care plan, revised in April, identified the colostomy with an intervention for ostomy care as needed. However, review of the May Physician’s Order Summary showed no physician orders for the colostomy or for the care to be provided, and there was a lack of documentation of completed colostomy bag changes and stoma care. During interview, the DON was unable to provide any additional information, and the facility’s colostomy and ileostomy care policy required that services provided or arranged by the facility, as outlined by the comprehensive care plan, meet professional standards of quality. The survey finding is that, for this resident, the facility did not ensure that colostomy care was supported by specific medical orders and documented care consistent with the resident’s assessed needs and the facility’s own policy.
Failure to Obtain Orders and Document Colostomy Care for a Resident
Penalty
Summary
Surveyors identified a deficiency in colostomy care for one resident when the facility failed to ensure care was provided in accordance with professional standards, the care plan, and physician orders. The facility’s colostomy care policy, dated January 22, 2026, required that colostomy care be provided per physician orders to maintain good skin care and monitor the condition of the stoma and surrounding skin. An annual MDS for Resident 16, dated March 17, 2025, showed the resident was cognitively impaired, required staff assistance for daily care needs, had intellectual disabilities, and had an ostomy. Review of the resident’s clinical record revealed there was no physician order specifying the colostomy size and no orders for changing the colostomy appliance, and there was no documented evidence that the colostomy appliance was being changed. In an interview, the Nursing Home Administrator confirmed the absence of a physician order for the ostomy size and the lack of documentation that the colostomy appliance was being changed for this resident. These findings demonstrate that the facility did not follow its own policy or obtain and implement necessary physician orders for colostomy care for this resident, resulting in a failure to provide and document appropriate ostomy services as required.
Plan Of Correction
The physician orders for Resident 16 were updated to include colostomy size with orders to change the appliance on 4/21/2026 with no ill effects noted. An audit of current in-house resident colostomy orders will be completed to ensure specification of size with orders to change appliance present. The Director of Nursing and/or designee will re-educate the Nursing Staff on verifying that resident colostomy orders specify size with orders to change the appliance. Newly hired and agency Nursing staff will be educated upon on boarding on verifying that resident colostomy orders specify size with orders to change the appliance. The Director of Nursing and/or designee will complete random audits weekly for 4 weeks and then monthly for 2 weeks to assure resident colostomy orders are present and specify size with orders to change appliance. with colostomy's have corresponding orders on the Treatment Administration Record (TAR). Audit results will be reviewed by the facility Quality Assurance Performance Improvement Committee to determine compliance or need for continuation of audits.
Failure to Follow Colostomy Care Policy for Two Residents
Penalty
Summary
The facility failed to provide proper colostomy care for two residents who were cognitively impaired and dependent on staff for daily care. For one resident, a quarterly MDS assessment documented the presence of an ostomy and a physician’s order directed that the colostomy bag and setup be changed every three days and that the bag be dated when changed per family request. During an observation with an LPN, the resident’s colostomy bag was found with no date marked anywhere on it. The LPN confirmed during interview that the colostomy bag was not dated and acknowledged that it should have been. For the second resident, a quarterly MDS assessment also documented cognitive impairment, dependence on staff for all daily care needs, and the presence of a colostomy. During an observation, an RN was seen preparing and changing the resident’s colostomy appliance. The RN cut the ostomy wafer at the medication cart without measuring the stoma, then cleaned the skin, applied skin prep, and placed the wafer and bag. The wafer was visibly large compared to the stoma, and the RN did not measure the stoma or apply the wafer close to it, instead stating she “just eyeballs it.” Review of the facility’s colostomy care policy showed that staff were required to measure the stoma using a measuring guide and trace and cut the wafer opening to the correct size, and the DON confirmed that staff should measure the stoma to cut the wafer to size.
Failure to Care Plan for Colostomy Management
Penalty
Summary
The facility failed to create a care plan for the care and management of a colostomy for two residents. Facility policy titled Colostomy/Ileostomy Care, dated 2/11/26, stated that its purpose was to provide guidelines to help prevent exposure of the resident's skin to fecal matter and to review the resident's care plan for special needs. Review of the clinical record showed that Resident R59 was admitted to the facility, had diagnoses including malnutrition, anal cancer, and difficulty walking, and the MDS dated 2/9/26 indicated an ostomy was present. A physician order dated 2/17/26 directed that the colostomy appliance wafer and bag be changed every week and as needed. Review of Resident R59's current care plan showed no care plan for colostomy care and management. Resident R72 was also admitted to the facility, had diagnoses including COPD, BPH, and cirrhosis of the liver, and the MDS indicated an ostomy was present. A physician order dated 2/17/26 directed that the colostomy appliance wafer and bag be changed every week and as needed. Review of Resident R72's current care plan also showed no care plan for colostomy care and management. During an interview on 4/10/26 at 9:40 a.m., the RNAC confirmed the facility failed to create a care plan for the care and management of a colostomy for both residents.
Failure to Provide and Document Ordered Colostomy Care
Penalty
Summary
The facility failed to provide and document colostomy care as ordered and per policy for one resident. The resident was admitted with diagnoses including partial intestinal obstruction, colostomy status, and chronic kidney disease, and had a documented left abdominal colostomy. An MDS assessment showed the resident had moderately impaired cognitive skills for daily decision making and required assistance ranging from partial/moderate to total dependence for hygiene, toileting, dressing, and bathing. Physician’s orders dated 8/27/2025 directed that colostomy care be provided and the colostomy bag emptied as needed, and the resident’s care plan instructed that the colostomy appliance be changed per physician’s orders. Review of the Treatment Administration Record from 11/16/2025 through 12/6/2025 showed blank entries for colostomy care and colostomy bag emptying, and concurrent review of the electronic medical record for the same period revealed no documentation that colostomy care or colostomy bag replacement had been provided. The treatment nurse confirmed there was no documentation of colostomy care or bag changes during that time and stated that, per facility protocol, such care should be documented on the TAR or in a progress note. A registered nurse similarly stated that colostomy care includes checking for signs of infection, cleaning the stoma site, and emptying or changing the colostomy bag, and that this care must be documented when done. The facility’s colostomy/ileostomy care policy required documentation of the date and time care was provided, the staff member’s name and title, skin condition and signs of infection, resident tolerance, refusals and reasons, and the signature and title of the person recording the data, which was not present for the identified period.
Failure to Assess, Order, and Monitor Urostomy and Self-Catheterization Care
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary urostomy and self-catheterization care and treatment for one resident in accordance with its own policies and procedures. The resident was admitted with diagnoses including urinary retention, paraplegia, and lack of coordination, and had an opening on the right lower abdomen for bladder drainage, using a straight catheter for voiding. The resident’s MDS documented an ostomy appliance, total dependence for toileting and dressing, and urinary incontinence, while cognitive skills for daily decision-making were independent. Despite these conditions, there was no physician order for urostomy care from admission until several days later, and the only order identified was to cleanse the urostomy site with normal saline, pat dry, and leave open to air, starting on a later date. The resident reported performing self-catheterization and primarily using personal supplies, requesting some items such as gauze from staff, but refused to show the stoma or provide details of the procedure. Nursing staff, including an LVN, stated that the resident performed self-catheterization but they had never assisted with or observed the urostomy care and were unaware of the condition of the skin around the stoma. The RN confirmed that urostomy care was not performed from admission until the date the urostomy care order was written, and that there were no physician orders, assessments, or documentation establishing that the resident could safely perform self-catheterization or indicating how often the resident catheterized. Further record review and interviews showed that the facility did not maintain required monitoring and documentation related to the resident’s urostomy and self-catheterization. There were no records of the resident’s intake and output, no documentation of urine output or its characteristics, and no evidence that the skin around the stoma was inspected for irritation or breakdown. The infection prevention nurse confirmed that the resident had not been evaluated for ability to perform self-catheterization, that there was no physician order for self-catheterization, and that no care plan addressing urostomy care and self-catheterization had been developed upon admission, contrary to the facility’s urostomy/ureterostomy care and self-catheterization policies, which require physician orders, competency verification, ongoing monitoring, and documentation of intake/output and peristomal skin condition.
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