HospitalInspections.org

Based on document review and interview, it was determined that the hospital failed to comply with the Condition of Participation, 42 CFR 482.42, Infection Prevention Control Antibiotic Stewardship.

Findings include:

1. The hospital failed to ensure that a hospital-acquired infection/infestation was reported as an incident/adverse occurrence to ensure that the event was investigated and included in the hospital's QAPI program. (A-771)

The Immediate Jeopardy began on 6/5/2023 due to the hospital's failure to report Pt #3's hospital-acquired infection/maggot infestation of a wound as an incident/adverse event to ensure the event was investigated, included in the hospital's quality and performance improvement program, and failed to implement actions to prevent reoccurrence. The IJ was identified on 8/31/2023, at COP 42 CFR 482.42, Infection Prevention Control Antibiotic Stewardship. The IJ was announced on 8/31/2023 at 4:00 PM during a meeting with the Chief Executive Officer, Chief Operating Officers (both hospital campuses), Directors of Quality Management (both hospital campuses), Director of Clinical Management, and Regional Chief Nursing Officer, and was not removed by the survey exit date of 8/31/2023.

Based on document review and interview, it was determined that for 1 of 1 patient (Pt. #3) reviewed for maggot infestation of a wound, the hospital failed to ensure that Pt #3's hospital-acquired infection/maggot infestation was reported as an incident/adverse event to ensure the event was investigated and included in the hospital's quality and performance improvement program and failed to implement actions to prevent reoccurrence.

Finding include:

1. The hospital's policy titled, "Event Reporting" (dated 06/2023), was reviewed on 8/31/2023 and required, "...Hospital personnel are responsible for reporting in a timely and efficient manner, patient and visitor events through the Event Reporting System... Event: Any occurrence or situation not consistent with the routine operation of the facility and which may have caused or may have the potential for causing injury to patients... Events include any threat to patient safety; can include physical injury, patient dissatisfaction, and near misses... Procedure: ...Enter the event into Event Reporting System at the time of the event but no later than 24 hours after it occurs or is discovered.... The DQM [The Director of Quality Management] or designee shall complete the basic facts regarding findings from the event investiggation in the quality review section of the system within 3 calendar days of the event.... The aggregated results of events, including trends, patterns and corrective action taken in response will be reported at each Patient Safety & Reliability Committee... and fowarded to Quality Council..."

2. The clinical record of Pt. #3 was reviewed on 8/30/2023-8/31/2023. Pt. #3 was admitted to the Hospital's Main Campus 3 West Medical Surgical Unit on 3/21/2023, with diagnoses of respiratory failure, intracranial hemorrhage (bleeding within the skull), hypertension (high blood pressure), diabetes mellitus (metabolic disorder causing high blood sugar levels), acute kidney injury, seizure disorder, and right upper extremity ischemia (reduced blood flow).

- Wound care notes and assessments indicated that Pt. #3 had an extensive, necrotic (dead tissue) wound of the right upper extremity and breast upon admission from a suspected DVT (blood clot in the vein).

- Wound Care Physician (MDN#1) notes between 5/12/2023-6/2/2023 indicated that the right arm/breast wound began to have light drainage with increasing odor from the drainage.

- A Nurse's (EN#8) Note on 6/6/2023 at 7:20 AM indicated that on 6/5/2023 at 10:00 AM, a large amount of maggots were found in the wound, underneath the right arm and axilla (armpit) during wound care. Treatment for the maggots was started on 6/5/2023 at 9:00 PM.

- Pt. #3 was transferred to the emergency room [another hospital/higher level of care] on 6/7/2023 at 5:15 AM due to GI (gastrointestinal) bleeding (had 2 episodes of vomiting blood).

Pt #3 did not return to the hospital due to Pt #3 expired at hospital where Pt #3 was transferred.

3. The Hospital's Incident Logs from March 2023-August 2023 were reviewed on 8/29/2023 and included only one event filed for Pt. #3. The log lacked an incident filed for the maggots found in the patient's wound on 6/5/2023.

4. Flash meetings from 6/5/2023-6/7/2023 included that Pt. #3 had maggots and was sent out to the ER (emergency room) on 6/7/2023. There was no documentation of any actions taken (i.e education or changes made) regarding this incident to prevent reoccurrence.

5. Pest Control Reports indicated that on 5/25/2023, inspectors came to the Hospital due to a reported sighting of a fly. The inspection report included, "Inspected rooms 301 and 309 (rooms on the same unit as Pt. #3)... No further fly activity or infestations found at time of service." There were no pest control inspection reports immediately following the maggot infestation. The next pest control inspection was not completed until 7/10/2023 (more than a month after the incident with Pt. #3).

6. Infection Control Meeting Minutes January 2023 to August 2023 were reviewed on 8/30/2023 and did not address the maggots found in Pt. #3's wound.

7. Quality Meeting Minutes for June-August 2023 were reviewed on 8/30/2023 and lacked documentation that Pt. #3's case was discussed as a part of the Hospital's quality assurance and improvement program.

8. An interview was conducted with the Nursing Supervisor (EN#13) on 8/30/2023, at approximately 9:54 AM. EN#13 stated that finding maggots in a wound should have been reported as an incident in the Hospital's event reporting system. EN#13 stated that there was no formal education regarding the issue with the maggots.

9. An interview was conducted with the Director of Quality (EN#14) on 8/30/2023, at approximately 10:47 AM. EN#14 stated that it was an unusual occurrence for maggots to be found in a wound and stated that an incident report was not completed for it. EN#14 stated that besides speaking with the family afterwards, EN#14 was not involved with any investigation of the event. EN#14 stated that MDN#1 took over with how to treat the maggots after they were found and the patient was transferred out the following day.

10. An interview was conducted with Pt. #3's Attending Physician (MDN#3) on 8/30/2023, at approximately 1:05 PM. MDN#3 stated that MDN#3 was made aware of a patient that had maggots growing in the wound but did not recall who the patient was. MDN#3 stated that there have been only 2 cases in the past 20 years, and that both of them "came from the outside." MDN#3 stated that MDN#3 believed it [the maggots] came from somewhere else (not this hospital). MDN#3 stated that if a patient came in with maggots, the nurse should have been able to identify the maggots upon admission. MDN#3 stated that it would not take 2 months to show signs of the maggots.

11. Interviews were conducted on 8/30/2023 with multiple staff at both hospital campuses including a Wound Care Nurse (EN#12), Wound Care Physician (MDN#2), the Infection Control Nurse (EN#3), and the Chief Executive Officer (CEO), who per interview were not made aware of the incident when maggots infested a patient's wound. EN#3 stated that EN#3 started in June and was not told of the incident until today (8/30/2023). MDN#2 stated that Pt. #3 was not his patient; however due to the sheer fact that it happened to any patient in the Hospital, MDN#2 would have expected to have been made aware of the incident. Based on the time of admission and the time the maggots were found on Pt. #3, MDN#2 stated, "That's [maggots in the wound] a problem. This certainly happened at [this Hospital]. The gestation time for flies is about 5-7 days, there is no way this happened in April or earlier. Best case scenario, this happened end of May or early June ... The initial infestation happened at [this Hospital]. I hope no one tells you otherwise." MDN#2 stated that after this was found, ideally the patient should have been isolated, moved to a different room, and that room should have been terminally cleaned thoroughly as anything left would hatch and continue the cycle, potentially landing on another wound or necrotic material next to patients. MDN#2 stated that some area of the wound would have had to be exposed or the dressing unsecured for the fly to access the wound or crawl under the dressing. EN#12 stated that EN#12 was not aware that a maggot infestation had occured. The CEO stated that he was not aware of any incidents of maggots at the hospital.

12. An interview was conducted with the Chief Operating Officer (EN#11) on 8/30/2023, at approximately 3:30 PM. EN#11 stated that there was no incident report or investigation regarding the maggots found in Pt. #3's wound.

13. A telephone interview was conducted with the Registered Nurse (EN#8) on 8/31/2023, at approximately 9:30 AM. EN#8 stated that the wound should be covered and secured at all times except during wound care. EN#8 stated that wound care can take an hour and the wound should be monitored at all times when uncovered (dressing removed). EN#8 stated that the betadine used to clean the wound dries within a few minutes and during this time the staff stay in the room and observe the wound until it dries and is redressed. EN#8 did not recall any flowers being in the room at the time and was not informed where or how the maggots got into the wound. EN#8 denied receiving any education or in-services regarding maggots.

14. A telephone interview was conducted with Wound Care Physician (MDN#1) on 8/31/2023, at approximately 10:15 AM. MDN#1 was notified that maggots were present in Pt. #3's wound and had ordered treatment with Dakin's (solution to treat infections). MDN#1 was not able to see Pt. #3 before Pt. #3 was transferred/discharged. MDN#1 stated that MDN#1 heard some rumors about Pt. #3 but nothing that made clinical sense. MDN#1 stated that there was no formal discussion with administration or leadership regarding this incident and MDN#1 had no idea where the maggots came from. MDN#1 stated that maggots can feed on the necrotic tissue and is a potential risk of infection. MDN#1 stated that all patients with wounds are at higher risk for potential maggot infestation.