GRIFFIN, GA – RENAISSANCE CENTER FOR NURSING AND HEALING

Based on observation, record review, review of the facility policy titled GA Abuse Prohibition- State of Georgia, resident and staff interviews, the facility failed to protect one resident (R) (#1) from neglect by not notifying the Physician and appropriately treating a left foot wound which became infested with maggots of 36 sampled residents.

On [DATE] a determination was made that the facility’s noncompliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents.

The Administrator, Regional Director of Operations (RDO), and Regional Director of Clinical Services (RDCS) were informed of the Immediate Jeopardy (IJ) on [DATE] at 1:45 p.m. The noncompliance related to the IJ identified to have existed on [DATE] when staff failed to act after discovering R#1 with black toes.

An interview was conducted on [DATE] at 10:30 a.m. with Physician BB. He stated on Saturday [DATE] a resident from the facility was brought into the emergency room for a complaint of infected toes on the left foot. Physician BB reported upon examination of R#1, her left foot was embodied with maggots. He did not count the maggots, but it was a lot. Physician BB stated on Sunday, [DATE], R#1’s left leg had to be amputated. He also revealed that R#1’s leg was sent to the pathologist. Physician BB provided the surveyor with a video of R#1’s foot with the maggot infestation. An interview on [DATE] at 11:15 a.m. with NP GG revealed she received a call and pictures on [DATE] informing her of the condition of R#1’s left foot. She stated she was informed by the caller that the toes on left foot were dark. NP GG revealed the last time she saw R#1 was on [DATE] and again on [DATE] the day before she was sent out to the hospital. NP GG stated she did not assess the resident’s feet on [DATE] and she did not assess the left foot on [DATE]. NP GG stated she does not look at any resident’s feet.

An interview on [DATE] at 12:45 p.m. with R#11 (R#1’s roommate with BIMS of 13, indicating cognition intact) revealed that R#1 would complain all the time that her feet were hurting. R#11 stated when her roommate would complain to her she would put her light on and let the nurse know. She stated she does not remember if the staff would look at the resident’s feet when she complained but the staff would bring something in for the pain. R#11 stated on occasion there would be flies in the room.

An interview was conducted on [DATE] at 1:00 p.m. with CNA ZZZ who stated on [DATE] between 10:30 a.m. -11:30 a.m. she went in R#1 room to give her a bed bath for the day. The resident had complaints of discomfort of the left foot. CNA ZZZ stated when she looked at R#1 left foot it was leaking maggots. She stated there were so many maggots in the residents left foot and on the bedding. She asked her coworker to have the nurse to come into the room. At that point she attempted to clean the maggots out with the washcloth, and she used two clothes that were full of maggots. CNA ZZZ stated around a thousand of maggots were inside of R#1’s foot and she could hear the maggots making a scratching sound.