Maggot Infestation Due to Inadequate Oral Care and Pest Control
Penalty
Summary
A resident with severe cognitive impairment, total dependence for activities of daily living, and multiple complex medical conditions including end-stage renal disease, respiratory failure requiring mechanical ventilation, and a tracheostomy, was admitted to the facility. The resident required total assistance for oral hygiene, toileting, bathing, and personal hygiene, as documented in the Minimum Data Set and interdisciplinary team records. Staff interviews and record reviews revealed that oral care was inconsistently performed, with some staff only cleaning around the lips and not the inside of the mouth, and not seeking assistance from licensed nurses or respiratory therapists when unable to provide complete oral care. Documentation of oral care was also lacking, and thick white material was observed on the resident's tongue and dried debris on the teeth and gums. Environmental observations and staff interviews indicated that the facility failed to maintain effective pest control measures. Flies and gnats were observed inside the facility, including in resident care areas and the conference room. The facility's trash dumpster was found uncovered and overflowing, and screen doors were not consistently kept closed or intact, allowing insects to enter the building. Staff acknowledged the presence of flies in resident rooms and the importance of keeping doors and windows closed, especially given the vulnerability of residents who were immobile and unable to protect themselves from pests. As a result of these failures, multiple staff members observed five to eight maggots emerging from the resident's right ear, right nostril, and mouth during a dialysis session. The resident was subsequently transferred to an acute care hospital, where diagnoses included septic shock, severe sepsis, and the presence of meal worms in the nostrils. The facility's lack of adherence to oral care protocols and pest control policies directly contributed to the maggot infestation and subsequent harm to the resident.