Failure to Implement Surveillance System for Infectious Skin Conditions
Penalty
Summary
The facility failed to implement a system of surveillance to identify, prevent, monitor, and report potential infectious skin conditions. Observations revealed that one resident had a persistent rash on her upper arms, chest, and back, which she described as feeling like bugs crawling on her. Another resident was observed with a rash over his arms, chest, and back, and had recently received permethrin cream for treatment after other interventions were unsuccessful; he reported relief from itching following this treatment. Clinical records confirmed the administration of permethrin cream, but there was no testing for scabies as the presentation was considered atypical, and a dermatology follow-up was pending. Interviews with the infection prevention nurse and the DON confirmed that there was no system in place to track and trend skin conditions, with each believing the other was responsible for this task. The nurse practitioner also indicated that tracking and trending of skin conditions was the responsibility of the infection prevention nurse.