Failure to Document Presence of Maggots in Resident's Medical Record
Penalty
Summary
Staff failed to ensure complete and accurate documentation in the medical record for a resident with multiple diagnoses, including type 2 diabetes mellitus, unspecified dementia, peripheral vascular disease, and severe morbid obesity. The resident was receiving ongoing wound care for a left medial leg wound, with changes in treatment orders documented over time. On one occasion, staff observed maggots between the resident's left great toe and second toe, but this finding was not documented in the medical record. Interviews revealed that a registered nurse saw approximately 10 maggots between the toes for two to three days but did not document this because she was instructed not to write 'maggots' in her documentation. The wound care nurse practitioner also confirmed the presence of maggots but did not document it, stating her focus was on wounds, not the area between the toes. Other staff members, including another RN and an LPN, were aware of the maggots either through direct observation or conversation but did not document the finding. The facility's policy on documentation requires that records be factual, objective, and resident-centered, but this was not followed in this instance. The lack of documentation regarding the presence of maggots between the resident's toes represents a failure to maintain complete and accurate medical records in accordance with accepted professional standards.