Failure to Provide Adequate Respiratory Care Resulting in Tracheostomy Site Infestation
Penalty
Summary
A resident with acute and chronic respiratory failure, hemiplegia, hemiparesis, and who was ventilator dependent with a tracheostomy, was found to have multiple fly larvae (maggots) in and on the tracheostomy site. The resident was totally dependent on staff for all care, including tracheostomy care, which was ordered to be performed every 12 hours with skin checks under the tracheostomy ties on each shift. Documentation in the Treatment Administration Record indicated that tracheostomy care was completed and signed off by various respiratory therapists. However, a nursing note documented the discovery of the larvae, and the resident was subsequently sent to the emergency room, where the infestation was removed. Hospital records confirmed the presence and removal of three larvae, with no further intervention required. Observations during the survey revealed multiple house flies and fruit flies present in the tracheostomy unit, landing on various surfaces. The resident's room was located next to an exit door leading outside, which staff had frequently used prior to the incident. The facility's policy on tracheostomy suctioning did not contain information on care required for fly larvae infestation. Interviews confirmed the infestation and the presence of flies in the unit, but attempts to interview the staff directly involved at the time of the incident were unsuccessful.