Failure of Medical Director Oversight During Scabies Outbreak
Penalty
Summary
The facility failed to ensure that the Medical Director (MD) adequately supervised the development and implementation of measures to mitigate a scabies outbreak, which ultimately affected 31 residents and persisted for six months. The Medical Directorship Agreement specified that the MD was responsible for coordinating medical care, reviewing incidents, and serving on the infection control committee. Despite these responsibilities, documentation and interviews revealed that the MD was not fully aware of the extent of the outbreak, did not track or trend scabies cases, and was unclear about the procedures for diagnosing scabies within the facility. Infection control meeting minutes showed ongoing issues with skin infections and housekeeping practices, but lacked detailed discussion or resolution of the scabies outbreak. Medical records indicated that residents received various treatments for scabies and related skin conditions, including permethrin, ivermectin, and topical steroids, with some cases requiring dermatology consultations after prolonged symptoms. The MD acknowledged that best practice involves two treatments of permethrin and that unresolved cases should be further investigated, but was unaware of the number of affected residents and the specifics of diagnostic procedures. Infection control documentation was inconsistent, with incomplete action plans and missing follow-up on deep cleaning and staff education, contributing to the prolonged outbreak and lack of effective resolution.