Failure to Administer Ordered Treatments and Implement Infection Control for Lice and Scabies
Penalty
Summary
The facility failed to properly implement its infection prevention and control program in response to multiple cases and exposures of lice and scabies among residents. Specifically, the facility did not administer ordered topical medications for lice and scabies as prescribed, and there was a lack of documentation regarding the administration of these medications. In several instances, the medication was not available at the scheduled time, and there was no evidence that the responsible staff notified the physician or nurse practitioner about the delay or non-administration. Additionally, there was no documentation of required isolation assessments or infection criteria evaluations for residents exposed to or diagnosed with lice and scabies prior to May, despite multiple exposures and symptoms being reported and observed by staff and residents. The facility also failed to obtain and document physician orders for contact precautions for affected residents at the time of exposure or diagnosis. Contact precautions were not consistently implemented or documented, and staff did not always follow facility policy regarding the use of personal protective equipment (PPE) and isolation procedures. Furthermore, the facility did not ensure that deep cleaning of resident rooms was performed in conjunction with treatment, as recommended by medical providers. There were inconsistencies in the cleaning of launderable and non-launderable items, and privacy curtains with visible stains were not always removed or laundered during deep cleaning, as reported by both residents and housekeeping staff. Residents involved in these deficiencies included individuals with significant medical histories, such as immunodeficiency, chronic illnesses, and cognitive impairments. These residents experienced repeated exposures and infestations, with one resident reporting psychosocial harm due to the ongoing situation. Staff interviews revealed a lack of clarity and follow-through regarding infection control protocols, medication administration, and communication with medical providers. The facility did not have a dedicated infection preventionist for a period during which these events occurred, further contributing to lapses in infection control practices.