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Based on observation, interview and document review, the facility failed to protect the rights of patients to be free from all forms of abuse, including neglect, resulting in the potential for harm and/or unsatisfactory outcomes for all patients receiving care in the facility. Findings include:

See tag: A-0145

1. The facility failed to provide adequate services (oral care) for seven (7) of ten (10) ventilated patients (#3, #4, #9, #10, #11, #12, #13) resulting in patient #3 developing maggots within the oral cavity and the potential for serious harm or injury to all ventilated patients requiring oral care.

Based on observation, interview and record review, the facility failed to provide adequate services (oral care) for seven (7) of ten (10) ventilated patients (#3, #4, #9, #10, #11, #12, #13) resulting in patient #3 developing maggots within the oral cavity and the potential for serious harm or injury to all ventilated patients requiring oral care. Findings include:

On 11/29/2022 at 1045 during a tour of the facility, accompanied by the Director (Staff U) and the Manager (Staff O) of the 20 bed Critical Care Unit (CCU), Staff U was queried whether there were ever flies in the CCU. Staff U and Staff O described a situation that had occurred in early September of 2022 (09/01/2022 @2100), where maggots were discovered in the oral cavity (of patient #3) during suctioning. Both Staff O and Staff U agreed there was a "root cause analysis (RCA) completed and an action plan was in place". They described an action plan that included the addition of a 24-hour oral care pack to be hung at the bedside to ensure oral care was completed every two hours per the facility policy. A request to review the RCA was made on 11/29/2022 at 1435, however it was later discovered there was no official RCA documentation available. Documents were reviewed indicating the incident did occur and that some new procedures and supplies were garnered in the CCU (that related to insect prevention/removal) as well as ordering additional supplies for appropriate oral care for ventilated patients.

*Note the changes occurred exclusively in the CCU and did not address ventilator patients in other units of the hospital including but not limited to the ED (Emergency Department) and PCU (Progressive Care Unit).

On 11/29/2022 at 1140 Staff U was queried regarding the process/procedure for ensuring adequate oral care for all ventilated patients, including those with a tracheostomy. Staff U stated, "we have new oral care kits that are hung bedside and have enough supplies to be used over the course of a 24-hour period." Staff U was further queried regarding how it was verified that oral care was completed, how standards of care and the facility policy was measured, i.e.: any auditing systems that were in place to ensure oral care was being adequately performed and documented per policy. Staff U deferred to Staff O who stated, "the techs hang the oral care packs when they arrive in the morning, there are no means of recording or reporting the usage of supplies being used. No, we have not done any document audits, or any other audits".

On 11/29/2022 at 1055 Staff U confirmed that there were no follow ups being done to ensure oral care was being done and documented in spite of appropriate supplies being available in the CCU.

Upon review of Patient #3's nursing flow sheets it was determined that patient #3 was intubated on 08/30/2022 at 1415 and oral care was not documented/completed until 08/31/2022 at 0518. The following are dates and times of oral care from intubation to discovery of the maggots.


08/30/2022 08/31/2022 09/01/2022 09/02/2022
1415 Intubated 0518 0109 0035
0931 0351 0427
1159 0502 0622
2042 1728 1135
2121 maggots discovered 1844
2205

**Per facility policy ventilated patients are required to receive oral care every two hours.
See below for policy details.

On 11/29/2022 at 1200 the CCU Medical Director, Staff S noted they were aware of the maggots found in Patient #3's mouth, and acknowledged a lack of documented appropriate oral care by staff for ventilated patients. Staff S further denied being included in an RCA process for the incident involving Patient #3.

On 11/29/2022 at 1210 a tour occurred on the Progressive Care Unit (PCU) with Staff U, the Director of PCU. Staff U listed the patient diagnosis types that could be housed on the PCU which included ventilated patient. Staff U confirmed that at the time of tour there were at least three patients in PCU requiring mechanical ventilation, (Patients #9, #10, and #11). While on the PCU a concurrent review of nursing flow sheets revealed oral care was not being completed/documented every two hours as required by the facility policy.

* For the purposes of space, the notation will be limited to a 48-hour period, however all records in their entirety are available for review.

On 11/29/2022 at 1240 Patient #9 was observed in room 269 with a tracheostomy, requiring mechanical ventilation. Patient #9's open chart (e-MAR) was reviewed with PCU Staff L and Staff U present. Patient #9 was a 68-year-old male admitted on 11/13/2022, review of oral care documentation revealed Patient #9 had oral care documented on 11/28/2022 at 0600 and the next documented oral care was recorded on 11/29/2022 at 1200. A lapse in oral care documentation of 30 hours was confirmed by Staff U and PCU Manager Staff L.

On 11/29/2022 at 1247 Patient #10 observed in room 270 on a mechanical ventilator, was a 51-year-old female admitted on 11/22/2022. Review of the e- MAR revealed Patient #10 had NO documented oral care on 11/28/2022 through the time of survey on 11/29/2022 at 1247. Further observation revealed no oral care supplies were stored at the bedside as previously verbalized by Staff U, as part of the described action plan implemented post the September 2, 2022 maggot findings in the CCU. When queried regarding oral care supplies RN Staff in the PCU unit were unable to locate the 24-hour oral care packs "implemented". At the time of tour Respiratory Care Staff BB stated, she could run over to the CCU to get the 24-hour pack. Both Staff U and Staff L confirmed a lapse in oral care for a minimum of 36 hours.

On 11/29/2022 at 1225 Patient #11 was observed in room 271 on a mechanical ventilator with a tracheostomy. Patient #11 was a 69-year-old female admitted to the facility on 11/20/2022 and was housed in the ED from 11/20/22 until approximately 1100 on 11/29/2022. Review of the e-MAR revealed Patient #11 was a chronic tracheostomy patient who presented to the facility's ED with a diagnosis of sepsis. Both Staff U and Staff L were unable to locate any oral care documentation dated 11/28/2022 through 11/29/2022 at the time of review.

On 11/29/2022 at 1400 during record review a request for records of all Ventilator Acquired Pneumonia (VAP) patients over the past 12 months was requested. Two (2)(pts. #12 and #13) of four (4) VAP Patients reviewed revealed inadequate or lack of oral care documentation.

*The notation of oral care will be limited to a 48-hour period to confirm inadequate oral care as follows:

On 11/30/2022 prior to survey exit it was confirmed by Staff A, B, D, & T "although the facility reported they completed an RCA in response to the maggot findings, the facility was unable to provide documentation reflecting implementation and monitoring of corrective actions. Current practice at the time of survey revealed inadequate oral care.

Documentation related to Patient #3 was received from the service excellence team manager Staff T including the letters sent to the complainant as well a "investigation notes". Documented communication from Staff T, (dated 09/12/2022, 09/16/2022 and 09/23/2022) reminding/requesting Staff U and Staff O, to enter any process improvements and/or action plans implemented be placed in RL (incident reporting system). Staff T, Staff B, and Staff D confirmed no additional information was added into the RL.

Document review occurred on 11/29/2022 at 1400 of the policy titled, "Oral Cleansing for the Intubated and Bi-PAP Patient - CCC/PCU," last revision date 3/23/2021. According to the policy on page one it stated the following:

I. Procedure
The purpose is to provide instructions for the oral care system for the intubated patients in the Critical Care Complex/Progressive Care Unit (CCC/PCU). Bacteria causing lower respiratory tract infections colonize in the mouth and oropharynx and promote the build-up of dental plaque. Protecting the oral cavity from outside contaminants may reduce infections and frequent and aggressive oral and dental care have been identified as preventative measures against acquiring ventilator-associated pneumonia (VAP) oral cleansing every 2 hours and as needed. Intubated/Bi-PAP patients will be assessed to determine the need for removal of oropharyngeal secretions every shift, and as needed (PRN), as well as prior to repositioning the tube or deflation of the cuff.

II. GENERAL INFORMATION:

A. 24-hour Oral Care System -
This system consists of the following supplies:
1. (1) packaged sheath covered yankauer, Y-connector, and suction handle.
2. (2) packages of suction toothbrush with, anti-plaque solution, mouth moisturizer and applicator swab.
3. (6) packages of suction swab with alcohol-free mouthwash solution, mouth moisturizer, and applicator swab.
4. (6) packages of suction swab with oral debriding agent, mouth moisturizer and applicator swab.
5. (2) packages 14 French suction catheter

B. The oral cavity is assessed on admission and each shift by the registered nurse (RN).

C. Unconscious or intubated/Biphasic Intermittent Positive Airway (Bi-PAP) patients are provided oral cleansing every 2 hours and as needed. Intubated/Bi-PAP patients will be assessed to determine the need for removal of oropharyngeal secretions every shift, and as needed (PRN), as well as prior to repositioning the tube or deflation of the cuff.

D. 24-hour Oral Care System is a 24-hour kit that will contain supplies to perform oral care 12 times / every (q) 2 hours throughout the day.

E. Suction canisters will be changed every 24 hours and PRN, if filled.




29955

During document review on 11/30/2022 at 1045 review of oral care for patient #12, a vent associated pneumonia identified patient, was conducted. According to documentation, patient (#12) was intubated on 2/21/2022 at 2303.

The following documentation was reviewed for a 72-hour period to confirm placement of endotracheal tube and oral care provided.


02/21/2022 02/22/2022 02/23/2022 02/24/2022
2030 Intubated 1151 0439 1010
0439 2053 1338
1646
1811

On 11/30/2022 at 1100 an interview occurred with staff M with facility staff member confirming oral care not provided q2h (every 2 hours) as required per facility policy.

On 11/30/2022 at 1110 a document review of oral care for patient #13 was conducted. According to the medical record the patient (#13) was intubated on 3/12/2022 at 0002 on 3/12/2022.
The oral care documented for patient #13 post intubation was as follows:

03/12/2022 03/12/2022 03/13/2022 03/14/2022
0002 Intubated 2230 1805 0444
2331 1235

On 11/30/2022 at 1120 an interview occurred with staff M with facility staff member confirming oral care not provided q2h as required per facility policy.

On 11/30/2022 at 1300 a document review of patient #4's medical record was conducted. Record review of patient #4 revealed the patient was intubated on 7/29/22 and oral care was documented as below.

07/29/2022 7/29/2022 07/30/2022 7/31/2022
1305 Intubated 1707 0404 0446
2319 0808 1143
1758 1617
2041 1731
2016


On 11/30/2022 at 1330 an interview occurred with staff M confirming oral care not provided q2h as required per facility policy.