Failure to Maintain Contact Precautions and Administer Scabies Treatment
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for one resident who was suspected of having scabies. The resident was admitted with multiple diagnoses, including schizophrenia and moderate cognitive impairment, and developed a non-improving rash with itching. Physician orders and facility policy required the resident to be placed on contact isolation and to receive Permethrin cream treatment for scabies, with isolation to continue for 24 hours after treatment. However, the resident's contact precaution signage was removed before the resident received the prescribed treatment, and the medication administration record showed that the Permethrin cream was not administered as ordered. Observations confirmed that the resident still had visible rashes and was no longer on contact precautions, despite not having received the required treatment. Interviews with facility staff, including the Infection Preventionist and Assistant Director of Nursing, verified that the resident should have remained on contact isolation until after treatment was completed, in accordance with facility policy. The failure to administer the prescribed treatment and to maintain contact precautions as required constituted a breakdown in the facility's infection prevention and control practices.