Failure to Revise Care Plans After Bed Bug Infestation in Shared Room
Penalty
Summary
The deficiency involves the facility’s failure to review and revise the comprehensive care plans for three cognitively intact residents sharing the same room after bed bugs were identified on one resident’s mattress. Resident 1, originally admitted in 2022 and readmitted in 2025 with diagnoses including DM II, cerebral infarction, and cardiomegaly, was dependent on staff for toileting hygiene, personal hygiene, showers, and dressing. Resident 2, admitted in July 2025 with DM II, osteomyelitis, and muscle weakness, required supervision or moderate assistance for hygiene and dressing. Resident 3, admitted in February 2025 with CVA, right-sided hemiplegia, end stage renal disease, and dependence on dialysis, required moderate to maximal assistance with hygiene and dressing. All three residents had documented capacity to make decisions and intact cognitive functioning. On the early morning of 10/9/2025, CNA 1, while assisting Resident 1 with perineal care, observed several small red insects on the white linen covering Resident 1’s mattress near the resident’s head. CNA 2 informed LVN 1, who then went to the room between 4 a.m. and 5 a.m. and also observed small insects on Resident 1’s bed. LVN 1 notified an RN and completed a skin assessment on Resident 1, noting no signs of bed bug bites such as red bumps or rash at that time. The room, shared by Residents 1, 2, and 3, was subsequently inspected by a pest management company, which confirmed bed bugs on one mattress and recommended heat treatment. Service notifications from the pest management company documented a positive identification of bed bugs in Room A on 10/9/2025 and completion of heat treatment on 10/10/2025. Despite these findings and the shared occupancy of the room by three residents, the facility did not revise or update the comprehensive care plans for Residents 1, 2, and 3 to address monitoring for skin problems or other complications related to potential bed bug bites. In an interview, the ADON acknowledged that the care plans were not revised after the bed bugs were found and stated that the care plans should have been updated with interventions for staff to monitor for skin problems and report issues to the physician. The facility’s own policy on developing and implementing comprehensive, person-centered care plans requires addressing each resident’s medical, physical, mental, and psychosocial needs.
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