Failure to Identify, Manage, and Control Scabies Outbreak
Penalty
Summary
The facility failed to identify and manage a scabies outbreak, resulting in the spread of the infestation among 31 residents and one direct care staff member. The surveillance system, specifically the outbreak line listings, was incomplete and lacked essential information such as specimen collection dates, lab results, prescribed medications, recovery dates, and current status for affected residents. The Infection Preventionist confirmed that these omissions hindered the ability to track and trend the outbreak effectively. Additionally, the infection control committee did not consistently document or discuss the outbreak in their meeting minutes, and there was no evidence of tracking, trending, or consistent plans to mitigate the outbreak. Nursing and housekeeping departments did not implement appropriate precautions to prevent the spread of scabies. Documentation showed delays and gaps in deep cleaning of affected rooms, and the Director of Housekeeping was unable to provide evidence of when deep cleaning started or stopped for rooms impacted by scabies. Staff education on scabies was not provided until four months after the initial cases were identified, indicating a significant delay in training direct care staff on infection prevention and control practices specific to scabies. Two residents with severe cognitive impairment were directly affected by the outbreak. One resident experienced ongoing skin issues, including rashes and itching, with delayed diagnostic and treatment interventions. There was confusion and inconsistency in the management of their condition, including inappropriate in-house diagnostic procedures and delayed dermatology consultation. The roommate of this resident also exhibited symptoms and was placed on isolation and treatment for possible scabies exposure. The medical director was not fully aware of the extent of the outbreak, as indicated by the line listings.