Failure to Provide Scheduled Hygiene Care Resulting in Maggot Infestation and Pressure Injury
Penalty
Summary
A ventilator-dependent resident with multiple complex medical conditions, including acute respiratory failure, chronic kidney disease, and dysphagia, was found to have not received regularly scheduled showers and bed baths as required by facility policy. The resident was completely dependent on staff for all activities of daily living, including personal hygiene and oral care. Documentation and interviews revealed that scheduled showers and bed baths were frequently missed due to high resident acuity and inadequate staffing, resulting in lapses in hygiene care. The resident's oral cavity was observed to be unclean, with thick yellowish coating and dried secretions, and the lips were dry and cracked. Oral care was not documented as provided on multiple shifts, and staff interviews confirmed that oral care and hygiene were often not completed due to workload demands. The resident developed a Stage III pressure injury on the left lateral side of the neck, which was attributed to tracheostomy ties and worsened over time. Moisture-associated skin damage was initially noted, and the wound deteriorated to a full-thickness skin loss. On one occasion, approximately 20 maggots were discovered around the resident's tracheostomy site and within the pressure injury wound. Staff interviews confirmed that the presence of maggots was observed by multiple staff members, including CNAs and respiratory therapists, during routine care. However, the incident was not properly documented in the resident's electronic health record, and required communication tools such as SBAR forms and progress notes were not completed. The physician and family were eventually notified, and the resident was transferred to an acute care hospital for further evaluation and treatment. Facility records and staff interviews indicated that the failure to provide scheduled hygiene care, including showers, bed baths, and oral care, was a recurring issue due to staffing shortages and high resident acuity. The lack of regular hygiene care contributed to poor skin condition, the development and worsening of pressure injuries, and ultimately, the maggot infestation. The facility's own policies on infection prevention, bathing, and tracheostomy care were not followed, and there was a lack of proper documentation and timely reporting of significant changes in the resident's condition.