Resident Dignity Compromised by Cockroach Infestation and Insects on Resident During EMS Transfer
Penalty
Summary
The deficiency involves a failure to maintain a resident’s dignity when the resident was found with multiple live cockroaches on his body and in his bed during preparation for transfer to the hospital. The resident had moderate cognitive impairment, required a wheelchair for mobility, and needed supervision with bathing and dressing. On the day of the incident, nursing documentation showed the resident became increasingly confused and disoriented to self and place, and EMS was called for evaluation of altered mental status. When EMS personnel arrived and turned the resident, they observed an unspecified number of live insects consistent with cockroaches crawling on the resident and in his bed. EMS staff reported that facility staff acknowledged a cockroach infestation and later filed an Adult Protective Services report. The emergency department provider note documented that the resident arrived at the hospital with an unspecified number of insects on him and was immediately cleaned by nursing staff. Due to altered mental status, the resident was minimally able to participate in the evaluation and could only nod or shake his head inconsistently. Interviews with facility staff revealed that the nurse who arranged the transfer did not observe cockroaches on the resident and stated EMS did not report this to her at the time. The nurse aide assigned to the resident that day reported hearing from another aide that EMS personnel had observed cockroaches on the resident and were stomping them on the floor while preparing him for transport, and she stated it had been several hours since she last provided personal care to the resident before his transfer. Additional staff interviews and external observations confirmed ongoing cockroach activity in the facility around the time of the incident. A nurse aide reported that cockroaches were “terrible” in the fall and winter, and that she had seen cockroaches on medication carts, on residents, in beds, on ceilings, and in resident rooms, including a prior incident where a resident had a cockroach on his clothing without being aware of it. The Maintenance Director acknowledged a cockroach infestation in November and December and stated staff had reported seeing cockroaches as recently as about one month prior, including reports of cockroaches found on residents. A pest control specialist who evaluated the building in late January described the facility as heavily infested with active cockroach activity. The Administrator confirmed frequent cockroach sightings in the facility during the preceding months and acknowledged awareness that EMS had reported seeing cockroaches on a resident being transferred to the hospital.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.