Other·August 18, 2022

42CFR §483.12 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident’s medical symptoms. §483.12(a) The facility must— §483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; 42CFR §483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning. The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents’ goals and preferences, and 483.65 of this subpart. 42CFR §483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. §483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: §483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards; §483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact. §483.80(a)(4) A system for recording incidents identified under the facility’s IPCP and the corrective actions taken by the facility. §483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. §483.80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary. 42CFR §483.90(i)(4) Maintain an effective pest control program so that the facility is free of pests and rodents. 22 CCR §72311. Nursing Service - General. (a) Nursing service shall include, but not be limited to, the following: (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. 22 CCR §72523. Patient Care Policies and Procedures. (a)Written patient care policies and procedures shall be established and implemented to ensure that patient-related goals and facility objectives are achieved. On 6/30/2022, the California Department of Public Health (CDPH) made an unannounced visit to the facility to conduct a complaint and facility-reported incident investigation about presence of maggots (fly larvae soft bodied, worm-like immature form of an insect that feed on the host's dead or living tissue and liquid body substances; myiasis is the infection of a fly larva in human tissue) in Resident 1's tracheostomy (a surgical hole [stoma] created at the front of the neck so a tube can be inserted into the windpipe to assist in breathing; the tube is connected to the ventilator). The facility failed to ensure Resident 1, who was dependent on staff for all activities of daily living (ADLs, such as dressing, personal hygiene, and incontinent care), was in a persistent vegetative status (showing no signs of awareness related to brain dysfunction), and was dependent on a ventilator (a mechanical breathing machine to provide oxygen [a chemical element found in the air as a colorless odorless tasteless gas that is necessary for life] to the body when the person is unable to breath on his/her own), was free from neglect (the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress), was provided with adequate care to the tracheostomy, and was free from infection to the stoma. Also, the facility failed to maintain an effective pest control program and be free of flies for Resident 1. As a result, on 6/29/2022, Family Member 1 (FM 1) noticed the area surrounding the tracheostomy, was infected with maggots. This placed Resident 1 at great risk of breathing complications including infection. FM 1 was disconcerted and upset to find the multiple maggots that had not been identified by the staff. On 6/30/2022 at 1:05 p.m., during entrance conference, the Administrator (ADM) stated the in-house census (population count) in the Sub-Acute (a lower level of care setting from a General Acute Care Hospital [GACH]) unit was nineteen (19) residents. On 6/30/2022 at 1:09 p.m., during observation and concurrent interview, the Infection Control nurse (IP), observed and confirmed the presence of a live fly resting on the window curtains of the conference room. A review of Resident 1's Admission Record indicated the facility admitted the resident, an 82-year-old female, on 9/18/2017 with diagnoses including chronic respiratory failure (when airways carrying oxygen to the lungs are narrow or damaged), tracheostomy tube, dependence on ventilator, and persistent vegetative state. A record review of Resident 1's Care Plan for the resident having a tracheostomy, last revised on 4/12/2019 and current, included in the interventions changing the tracheostomy dressing every shift and as needed for soiling (when dirty) and observing the (stoma) site every shift and document findings. A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 9/6/2021, indicated the resident was unable to communicate and required total care from staff for all ADLs. A review of Resident 1's Care Plan for Activities of Daily Living Function, last revised on 4/27/2022, included in the interventions anticipating and meeting the resident’s needs daily, and conducting skin inspection (including stoma site) every shift and as needed, observing for redness, open areas, scratches, cuts, bruises, and report changes to the nurse. A review of Resident 1's Change in Condition Evaluation, dated 6/29/2022 at 1:45 p.m., indicated the resident had "small white bugs noted around tracheostomy." On 6/30/2022 at 1:24 p.m., during an interview, Respiratory Therapist (RT, a health care discipline specializing in the promotion of optimum cardiopulmonary function) 1 stated the RTs in the Sub-Acute unit assessed the residents' respiratory status, oxygen saturation (amount of oxygen measured in the blood), changing and checking tracheostomy and securing the ties (to hold the tube in place) and checking the ventilators setting and proper functioning. RT 1 stated calling off for 6/29/2022 and notifying the Director of Nursing (DON) 24 hours prior to the scheduled shift (7 a.m. to 7 p.m. shift) but no replacement was provided to the unit. RT 1 stated it was very important to have RTs around the clock due to the residents having tracheostomy and ventilators. RT 1 indicated neglect was a form of abuse and not providing the residents with RT services was an example of neglect. During the interview, a fly was observed in the conference room which was confirmed by RT 1. On 6/30/2022 at 1:57 p.m., during an interview, Registered Nurse 1 (RN 1) stated RN 1 assessed Resident 1's tracheostomy on 6/29/2022 after 1:20 p.m. RN 1 stated, "I have never encountered anything like that before." RN 1 indicated the gauze (a loosely woven, almost translucent fabric that is used to bandage wounds) was clean on the outside. RN 1 stated, "When we opened up the gauze, it looked like fly larvae or maggots." RN 1 stated the licensed nurses were assigned to do the tracheostomy care for that morning as there was no RT on duty. RN 1 said Resident 1 did not receive tracheostomy care for the shift prior to FM 1 identifying the maggots. RN 1 stated, "this was sad, really horrible." RN 1 then stated, "It is true, the maggots, it is what I saw. I never want to see that again." On 6/30/2022 at 2:50 p.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated on 6/29/2022, Resident 1's tracheostomy had maggots around the stoma, and they were alive and moving. LVN 1 confirmed that there was no RT in the morning and the tracheostomy care was not provided to Resident 1 until after FM 1 saw the maggots on 6/29/2022 around 1:30 pm. On 7/1/2022 at 2:15 p.m., during a telephone interview, the facility ' s contracted pest control company Service Manager 1 (SM 1), stated flies land on food sources where they can leave their eggs, which then become larvae (maggots). SM 1 stated that for the eggs to develop into maggots, it could be from twenty-four (24) hours to a week. On 7/1/2022 at 3:52 p.m., during an observation of Resident 1 in the presence of LVN 1, Resident 1 ' s tracheostomy and surrounding skin was observed to be reddened in color. On 7/1/2022 at 4:43 p.m., a live fly was observed at the lobby doors beside the ADM ' s office. The DON present at the lobby confirmed the sighting of the live fly. On 7/1/2022 at 4:52 p.m., during an interview, the DON stated that for the tracheostomy, the dressing used is a "T-drain" (a gauze with a T-slit to provide a snug fit around tubes) and is not taped down onto the resident ' s skin. The DON stated the licensed nurses do not open (remove) the wound dressing if it does not look soiled from the outside. DON stated having maggots in the tracheostomy can lead to infection because flies transmit bacteria. On 7/1/2022 at 7:24 p.m., during an interview, the DON stated the Sub-Acute unit licensed nurses and the RTs chart on the form titled, "Daily Sub-Acute Charting." During concurrent review with the DON, the Daily Sub-Acute Charting had no documentation of the stoma status on: - 6/27/2022, timed at 12:01 a.m., and at 10:33 a.m. - 6/28/2022, timed at 1:58 a.m. and at 10:44 a.m. - 6/28/2022, timed at 10:57 p.m. The DON stated 24 to 48 hours was what was understood on the developmental stages from fly eggs to becoming maggots. The DON stated licensed nurses and RTs were to document their assessment every shift. A record review of an undated job description titled "Respiratory Therapist" provided by the facility indicated the position summary as, "The purpose of your job is to perform the duties of respiratory care upon the physician ' s request by following the federal, state, and local guidelines that govern the facility and as directed by the DON and Administrator." The job description also stated that Respiratory Therapists will "Relate all pertinent information concerning a resident ' s condition to a charge nurse as required. They will be committed to always doing the right thing." A record review of an undated job description titled, "Licensed Vocational Nurse" indicated the position summary, "The purpose of your job position is to provide each resident with routine daily nursing care in accordance with current federal, state, and local standards that govern the facility, and as directed by your supervisors." The job description also indicated that essential duties and responsibilities include, "Dressing wounds" and "Accurate and detailed charting of resident ' s progress notes." A review of an undated document provided to the facility by the pest control company titled, "House Fly Larvae," indicated, "House fly populations can be harmful to human health: they carry multiple pathogens (microorganisms that cause or can cause diseases) and have been linked to the spread of a number of diseases ... House fly eggs look like small grains of rice. Eggs hatch within 24 hours, and house fly larvae emerge. House fly larvae, or maggots, appear similar to pale worms." A review of the facility's current policy and procedure titled, "Departmental (Respiratory Therapy) - Prevention of Infection," revised on 11/2011, indicated, "The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff .... The following information should be recorded in the resident ' s medical record: ... 4. All assessment data obtained during the treatment." A review of the facility's policy and procedures titled, "Tracheostomy Care" last revised 8/2013 and current, indicated procedure guidelines to inspect skin and stoma (surgical opening) site for signs or symptoms of infection, leakage, subcutaneous crepitus (air pockets under the skin) or dislodged tube. The policy also states, "Document the procedure, condition of the site, and the resident ' s response." A review of a facility's policy and procedures titled, "Activities of Daily Living (ADL), Supporting," last revised 3/2018 and current indicated, "Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene." A review of the facility's current policy and procedure titled, "Pest Control" with a revised date of 5/2018 indicated, "Our facility shall maintain an effective pest control program." The policy also stated, "This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents." A review of the facility's policy and procedures titled, "Abuse Prevention Program" last revised 8/2021 indicated the policy statement, "Our residents have the right to be free from abuse, neglect, misappropriation of property and exploitation (action of treating someone unfairly in-order to benefit from their work)." The facility failed to ensure Resident 1, who was dependent on staff for all ADLs, was in persistent vegetative status, and was dependent on a ventilator, was free from neglect, was provided with adequate care to the tracheostomy, and was free from infection to the stoma. Also, the facility failed to maintain an effective pest control program and be free of flies for Resident 1. As a result, on 6/29/2022, FM 1 noticed the area surrounding the tracheostomy, had an infestation of maggots. This placed Resident 1 at great risk of breathing complications including infection. FM 1 was disconcerted and upset to find the multiple maggots that had not been identified by the staff. Based on the reasonable person concept, due to Resident 1’s severely impaired cognition and medical condition, an individual subjected to neglect, may have psychological effects including feelings of hopelessness, helplessness, and humiliation. The above violations jointly, separately, or in combination, presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result to Resident 1.