Failure to Implement Timely Infection Control and Treatment for Scabies
Penalty
Summary
The facility failed to implement effective infection prevention and control practices for a resident diagnosed with scabies. After a dermatology evaluation confirmed scabies, the resident was not placed under contact precautions until two days after the diagnosis, despite recommendations to treat as scabies being made earlier. The resident continued to share a room with two other residents, who were not placed on isolation or monitored for symptoms, even though they were in close contact. The facility did not have an available room for isolation, and only the affected resident was placed on isolation precautions within the shared room, while the roommates were allowed to move freely within the room and the facility. The prescribed treatment for scabies, including Ivermectin and Permethrin cream, was not administered as ordered. Documentation showed that Permethrin cream was not given until twelve days after the diagnosis and eight days after the physician's order, with notes indicating delays due to waiting for the family to provide the medication. There was no evidence that the physician was notified about the missed doses on the specified dates. The resident, who had limited cognitive capacity and required maximal assistance with activities of daily living, experienced worsening skin conditions, including open, severe skin wounds, and was eventually transferred to a general acute care hospital for further evaluation and treatment. There was also a lack of monitoring and assessment for the two roommates who were exposed to the resident with scabies. Progress notes and interviews confirmed that no formal documentation, daily assessments, or diagnostic testing were conducted for these close contacts. The facility did not establish an effective surveillance system or maintain an accurate line listing of symptomatic residents and staff, as required by their own policies and CDC guidelines. This failure to follow infection control protocols and physician orders contributed to the spread and worsening of the infection.