Inadequate Infection Control Program Leads to Scabies Spread
Penalty
Summary
The facility failed to develop and implement a comprehensive infection control program to prevent the spread of infectious diseases, specifically scabies, among its residents. This deficiency was identified through observations, review of the facility's infection control tracking logs, and staff interviews. The facility's policy for Infection Prevention and Control, last reviewed on December 4, 2024, was intended to systematically prevent, identify, control, and reduce the risk of infections. However, the facility did not adhere to its own policy, as evidenced by the inadequate management of scabies cases among residents. Resident 56, who was admitted with diagnoses including heart failure, hypertension, and anxiety, was found to have a rash related to scabies. Despite multiple nursing notes and physician visits addressing the resident's itchy rash, there was a lack of comprehensive and accurate skin assessments. The resident's condition was not properly documented, and the facility failed to implement appropriate contact precautions and treatment in a timely manner. The resident's condition worsened over time, leading to a dermatology consultation that confirmed a scabies diagnosis. Additionally, Resident CR1, who shared a room with Resident 56, was not notified of the scabies diagnosis nor offered treatment as recommended by the dermatology office. This oversight further highlights the facility's failure to implement proper infection control practices. The Assistant Director of Nursing (ADON) confirmed that the facility did not follow its established policy and procedures for skin assessments, contributing to the spread of scabies among residents.
Plan Of Correction
Resident 56 skin check is current. Resident CR1 deceased. To identify residents with potential to be affected, DON/designee will audit residents to ensure skin observations are current and issues identified will be addressed. To prevent from re-occurring, DON/designee will educate licensed nursing staff on skin assessment policy. To monitor and maintain compliance, DON/designee will audit 5 residents weekly x 4 then monthly x 2 for current skin assessments. All results will be brought to QAPI committee.