Resident Subjected to Prolonged Involuntary Seclusion Due to Misdiagnosed Rash
Penalty
Summary
A resident was admitted to the facility and subsequently developed a rash, which was initially documented on both arms and upper thighs. The resident was placed on contact isolation precautions for suspected scabies, as documented in the care plan and physician's orders. Despite treatment with Ivermectin and Permethrin, and ongoing provider assessments, the resident remained on isolation for an extended period. Progress notes indicated that the rash persisted and changed locations, but providers did not consult CDC guidelines for scabies treatment, and the isolation precautions continued based on facility protocol rather than updated clinical assessment. The resident remained on isolation for a total of 78 days, during which time he reported feeling confined and unable to receive showers for a significant portion of the isolation period. It was only after a dermatology consult that the rash was diagnosed as atopic dermatitis, unrelated to scabies, and isolation precautions were discontinued. Interviews with staff confirmed that the decision to maintain isolation was a collaborative process, but providers acknowledged not referencing CDC guidelines and that the facility determined the duration of isolation. The prolonged and unnecessary isolation resulted in the resident being involuntarily secluded due to a misdiagnosis.