Failure to Provide Wound Care per Orders Resulting in Infestation and Amputation
Penalty
Summary
A deficiency occurred when a resident with a history of peripheral vascular disease, cardiac arrest, and a left below-knee amputation (BKA) with chronic infection did not receive treatment and care in accordance with professional standards of practice. The resident's care plan included interventions for a left BKA stump infection, antibiotic therapy, and regular wound care, with specific orders for wound cleansing, dressing, and monitoring. Despite these orders, the resident's left stump was found to be infested with maggots and roaches, and the wound was described as necrotic, hard, and covered with eschar. The infestation was discovered after the resident had been outside in the smoking area, and staff interviews revealed that the wound was often left open to air, and the resident was known to be non-compliant with keeping dressings in place and with some aspects of care. Multiple staff members, including nurses and CNAs, reported that the resident frequently refused wound care and would remove dressings, particularly when going outside to smoke. There were also indications that the wound was not always covered as ordered, especially when the resident left the building. Staff interviews indicated that the presence of maggots was not immediately identified, and there was uncertainty about when the last wound care was performed. The wound care doctor and facility staff acknowledged the resident's non-compliance and the chronic necrotic state of the wound, but the infestation was not detected until it had progressed, resulting in the need for hospital transfer and subsequent above-knee amputation. Documentation and interviews confirmed that the facility failed to ensure consistent wound care and monitoring in line with professional standards, particularly regarding wound coverage and inspection for pests. The resident's care plan and physician orders were not fully implemented, and there was a lack of timely identification and response to the wound infestation. The failure to provide appropriate treatment and care as ordered and to monitor for changes in the wound condition led to the identification of an Immediate Jeopardy situation by surveyors.