Failure to Timely Report Neglect and Notify Authorities Following Maggot Infestation
Penalty
Summary
A ventilator-dependent resident with multiple complex medical conditions, including acute respiratory failure, chronic kidney disease, and dysphagia, was found to have maggots present around the tracheostomy site. The resident was non-verbal, unresponsive, and fully dependent on staff for personal and oral hygiene. Observations revealed poor oral hygiene, with a thick yellowish coating on the tongue, dried secretions, and cracked lips. The care plan required oral care every shift, but staff interviews indicated that scheduled hygiene care, including showers and bed baths, was often missed or delayed due to high resident acuity and inadequate staffing levels. On the morning the maggots were discovered, a respiratory therapist identified approximately 20 maggots around the resident's tracheostomy site. This finding was communicated to nursing staff, including the outgoing and incoming registered nurse supervisors, and subsequently to the Director of Nursing and the facility administrator via group text. Despite this, there was no immediate documentation of the incident in the resident's electronic health record, no completion of required communication tools, and no timely notification to the California Department of Public Health (CDPH) as mandated by state regulations. The resident's representative was also not informed of the specific reason for the hospital transfer, as staff were instructed not to disclose the presence of maggots. Staff interviews revealed that the administrator, upon learning of the incident, did not notify CDPH or initiate an internal investigation as required by facility policy. Nursing staff acknowledged that the presence of maggots was not reported or documented appropriately, and that the incident was not communicated to the resident's family. Facility policies reviewed indicated the requirement for immediate reporting of suspected abuse, neglect, or injury of unknown source to the administrator and appropriate authorities. The failure to promptly report the incident and notify the resident's representative resulted in a delay in regulatory oversight and impeded timely intervention.