The December 5 incident at Temecula Healthcare Center violated the resident's physician orders, which specifically called for gentle cleansing with warm water only. Instead, LVN 1 used a commercial wound cleanser containing sorbitol as its second ingredient on the delicate peristomal skin surrounding the man's colostomy opening.
The resident reported the incident as physical abuse the next day, telling staff the pain was so severe "he had to cover mouth from screaming." The work had to be completely redone during the following shift using the proper water-only method.
Resident 2's physician orders were clear and specific. His Summary Order Report from November 13 instructed staff to "change colostomy bag PRN if soiled or dislodgement" and "cleanse stoma area & dry gently." The orders made no mention of commercial cleansers or chemicals.
The facility's own treatment nurse confirmed the proper protocol during a December 10 interview with state inspectors. The treatment nurse stated that "the peristomal skin would be cleansed with gauze soaked with normal saline" and emphasized that "wound cleanser would not be used on the peristomal skin, as it would cause burning."
The Director of Nursing echoed this understanding, telling inspectors that staff "usually they would cleanse the peristomal area with normal saline" when changing colostomy bags according to physician orders.
Yet on December 5, LVN 1 did exactly what the treatment nurse said would cause burning. The licensed vocational nurse confirmed to inspectors that she had used the commercial wound cleanser on Resident 2's peristomal skin during the colostomy bag change.
The evening had already been difficult for the resident. His colostomy appliance had been leaking throughout the PM shift, requiring two complete bag changes at 8:00 p.m. and 9:50 p.m. due to "leaking brown BM."
During those earlier changes, staff had followed proper protocol. The health status note from that evening documented that "peristomal skin cleansed with warm water, dried thoroughly, and new appliance applied with proper seal. No redness or skin breakdown noted."
But something went wrong during what appears to have been a third bag change later that shift. Instead of the gentle warm water cleaning that had been used successfully twice before, LVN 1 reached for the commercial wound cleanser.
The resident's immediate reaction left no doubt about the severity of his pain. He told investigators the liquid "felt like alcohol to his open wound" and caused "unbearable" pain that forced him to muffle his screams.
Professional guidelines support the resident's physician orders and the facility's stated protocols. The Wound, Ostomy, and Continence Nurses Society published clear guidance in July 2024 on proper colostomy care: "Clean the skin around the ostomy with warm water and a washcloth or soft paper towel and pat dry."
The professional standards include an explicit warning against exactly what happened to Resident 2: "Do not use alcohol or any other harsh chemicals to clean the skin around the ostomy. They can cause the skin to get sore."
The timing suggests LVN 1 may have been working under pressure during a challenging shift. Two previous bag changes in less than two hours indicated the resident was experiencing significant leakage issues that required immediate attention and careful reapplication of the colostomy appliance.
But the resident's report the following day made clear that staff pressure did not excuse the painful violation of his care orders. He specifically described the incident as physical abuse, emphasizing both the intensity of his pain and his belief that the nurse's actions were inappropriate.
The fact that the work had to be redone during the next shift suggests the improper cleaning may have compromised the colostomy bag's seal or irritated the skin sufficiently to require additional intervention.
Colostomy care requires particular gentleness because the peristomal skin lacks the protective barriers of normal skin. The surgical creation of the stoma leaves surrounding tissue vulnerable to chemical irritation and breakdown. Physician orders for water-only cleaning recognize this vulnerability.
The inspection found that LVN 1's use of the commercial cleanser violated both the resident's specific physician orders and established professional standards for ostomy care. The wound cleanser's sorbitol content made it particularly inappropriate for the delicate peristomal area.
State inspectors classified the violation as causing minimal harm to few residents, but the resident's own account suggests the psychological impact may have been significant. His description of having to stifle screams indicates a level of distress that extends beyond temporary physical discomfort.
The incident raises questions about staff training on colostomy care protocols and whether LVN 1 understood the difference between wound cleaning products and the gentle methods required for ostomy maintenance. The facility's own treatment nurse clearly understood the distinction, yet somehow this knowledge failed to reach the bedside during a critical moment of care.
For Resident 2, the evening that began with routine appliance maintenance ended with a traumatic experience that he felt compelled to report as abuse. His colostomy bag had leaked twice, requiring careful cleaning and reapplication, but the third intervention left him in pain severe enough that he feared his own screams.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Temecula Healthcare Center from 2025-12-31 including all violations, facility responses, and corrective action plans.