Failure to Monitor and Treat Resident's Cancerous Lesion Resulting in Maggot Infestation
Penalty
Summary
A resident with dementia and severe cognitive impairment was admitted to the facility with multiple pre-cancerous lesions on the scalp, including one on the right temple. Dermatology consultations identified the need for follow-up and, eventually, a MOHS procedure after a biopsy confirmed squamous cell carcinoma. Despite initial treatment with Aquaphor ointment as ordered, documentation shows that after this course ended, the lesion was left untreated for several months, from February to late June, with no evidence of ongoing assessment or monitoring of the wound during this period. The facility's policy required weekly skin checks and documentation of any wounds, but records failed to show that the right temple lesion was assessed or documented in weekly skin checks from December through early September. During this time, the resident's family declined further dermatology appointments and requested in-house wound care, but there was no evidence of consistent wound assessment or treatment until the wound's condition worsened. Orders for topical antibiotics and other treatments were only initiated after a significant lapse in care. The deficiency culminated when staff discovered maggots in the resident's right temple wound, prompting transfer to an acute care hospital. Hospital records confirmed a large, necrotic wound with maggot infestation, and interviews with facility staff and the DON acknowledged the lack of wound assessment and treatment for several months. The failure to monitor, assess, and treat the resident's wound in accordance with professional standards led to the development of a severe wound with maggot infestation.