Failure to Provide Consistent Wound Care and Monitoring Resulting in Maggot Infestation
Penalty
Summary
The facility failed to consistently assess, monitor, and provide wound care treatments as ordered for a resident with existing pressure ulcers. Upon admission, the resident had chronic ulcers on both heels, osteomyelitis, and vascular dementia, and was cognitively impaired. The initial skin assessment documented the presence of pressure wounds, but there was no evidence that wound photographs or measurements were taken during the resident's stay, despite facility policy requiring such documentation. Nursing staff did not consistently complete or document daily wound care treatments as ordered by the physician, with several days lacking signatures or indicating refusals without further follow-up. Multiple staff interviews and record reviews revealed that wound dressings were frequently soaked, malodorous, and not changed as required. Staff reported that nurses on certain shifts did not have access to the camera for wound documentation, and that wound care was sometimes signed off as completed by one nurse but not actually performed. The resident's family and therapy staff noted a persistent foul odor and the presence of flies in the resident's room. On one occasion, a nurse signed off on all treatments for a medication cart but did not perform them, expecting other nurses to complete the tasks, which did not occur. The resident's condition deteriorated, and maggots were discovered in the left heel wound during a dressing change, prompting immediate hospitalization. Hospital records confirmed the presence of maggots and noted that the wounds appeared uncared for, with necrotic tissue and excessive drainage. The resident required removal of maggots and antibiotic treatment for the infected wounds. Facility leadership acknowledged missed opportunities for wound evaluation, daily rounding, and ensuring that wound care standards were upheld during the resident's transition and stay.