Failure to Provide Ordered Wound Care Resulting in Maggot Infestation
Penalty
Summary
A resident with moderate cognitive impairment and diagnoses including chronic obstructive pulmonary disease and cognitive communication deficit had a physician order for daily dressing changes to a left medial ankle venous wound. Documentation and interviews revealed that wound care for this resident was not completed for five consecutive days, as confirmed by the Director of Nursing. During this period, there was no documentation of wound care being performed for several days. The deficiency was discovered when an LPN found the resident's ankle dressing saturated and dated five days prior. Upon removing the dressing, live maggots were found in the wound bed. The LPN immediately sought assistance from an RN, who contacted the on-call physician, the DON, the resident's family, and hospice. The physician ordered the resident to be sent to the hospital. The incident was reported, and it was verified that the facility failed to ensure wound care was completed as ordered for the resident.