Failure to Maintain Effective Pest Control Program Resulting in Maggot Infestation in Wound
Penalty
Summary
A deficiency occurred when the facility failed to maintain an effective pest control program, resulting in a resident being found with live maggots in a stage 3 pressure ulcer on the right heel. The resident, a 32-year-old male with multiple pressure ulcers, paraplegia, and a history of refusing wound care, was admitted with several wounds but no maggots present at admission. Over the course of his stay, the resident intermittently refused wound care, and on the day maggots were discovered, he had refused care for at least one day. Nursing staff observed maggots in the wound dressing and notified the physician, but the resident initially refused to be sent to the emergency room. Observations and interviews revealed that the resident often spent extended periods outdoors and sometimes refused wound care, which contributed to the wound's condition. Staff noted that the dressing was sometimes moist and that the resident's room had a window screen that was not fully adjusted, potentially allowing flies or gnats to enter, although no flies or gnats were observed at the time of inspection. Additionally, flies were observed in another resident's room, and staff reported that food debris sometimes attracted flies, but no infestation was documented. The facility's pest control logs indicated regular pest control visits, but no issues were noted prior to the incident. Housekeeping practices were found to be inconsistent, as the resident's room and linens were not cleaned or changed on the night the maggots were discovered due to the absence of housekeeping staff. Nursing staff did not recall whether the room was cleaned or linens changed that night. The Housekeeping Manager confirmed that deep cleaning and linen changes did not occur until the following afternoon. The facility's pest control policy required the building to be kept free of insects and rodents, but the lack of timely cleaning and environmental controls contributed to the deficiency.
Removal Plan
- Resident #1's wound was cleansed per wound protocol when maggots were discovered.
- Resident #1's room was cleaned and sanitized in accordance with the facility's cleaning and disinfection policy.
- A facility-wide environmental inspection was completed by the Maintenance Director to ensure all windows, screens, and entry points were intact and secure.
- Three additional fly zap lights were ordered and installed in B Hall Dining Room, C Hall Dining Room, and E Hall dining room.
- The effectiveness of the newly installed Zap Lights will be monitored utilizing the environmental checklist by the Housekeeping Supervisor and Maintenance Director or designee.
- The Pest Prevention Technician assisted the facility with the wipe down method in rooms of residents with treatment orders, entailing wiping down surfaces and walls.
- A comprehensive skin and wound audit was completed for all residents with pressure injuries to ensure no other residents were affected.
- All staff were in-serviced on the facility's Pest Control Program, including pest prevention, environmental inspection, and staff reporting.
- Training provided to all staff on the cleanliness of resident rooms to ensure rooms remain as free as possible of items that may attract pests, and on cleaning procedures in the event pests are identified.
- Housekeeping cart is available in E hall housekeeping closet for after-hour use.
- Pest control vendor visits increased and three additional fly lights installed in key areas.
- Maintenance initiated an environmental inspection log for all window seals, screens, and potential pest entry points.
- Environmental Services implemented a cleaning checklist focusing on food debris and sanitation in resident rooms and dining areas.
- Nurses received re-education on wound care refusal documentation, physician notification, and resident education procedures.
- The Quality Assessment and Assurance Committee will review the pest control log for any pest control issues, and the Admin/DON/designee will complete 5 observations.
- If any pest control issues or deficient practices are discovered, the Admin/DON/designee will provide additional training for staff, including pretest, inservice, post-test, and return demonstration.
- The results of the Admin/Director of Nursing/designee reviews will be presented to the Quality Assessment and Assurance Committee for review of trends and/or negative findings and further recommendations.
- The committee will make recommendations for further education as warranted and develop further performance improvement plans as necessary.