Failure to Implement Infection Control Measures During Scabies Outbreak
Penalty
Summary
The facility failed to implement effective infection control measures and comprehensive infection surveillance to prevent the transmission of scabies among residents. A resident with a history of anoxic brain damage and cognitive communication deficit was diagnosed with scabies following dermatology appointments, with clinical notes indicating a spreading, itchy, and bleeding rash. Despite a physician's order for scabies treatment and recommendations for contact precautions, the facility did not document the resident's treatment for scabies, implement transmission-based precautions, or monitor other residents for symptoms as part of their infection control program. The Assistant Director of Nursing acknowledged that CDC guidelines recommend contact precautions after initiation of therapy but stated these were not enacted due to the belief that the treatment was prophylactic rather than for an active infection. Subsequent dermatology evaluation confirmed crusted scabies and recommended enacting scabies protocols according to facility and state guidelines, including isolation of contaminated clothing and treatment of household contacts. The Director of Nursing reported that after this diagnosis, skin assessments were conducted on all residents, and 19 additional residents with rashes were treated with a scabicidal. However, prior to this, there was no evidence of early detection, isolation, or infection control practices being implemented following the initial diagnosis, as required by both facility policy and CDC guidelines. Multiple residents developed symptoms consistent with scabies, including pruritic rashes, severe itching, and discomfort. Progress notes for several residents documented exposure to a confirmed scabies case and the presence of rashes consistent with scabies infestation. Interviews with affected residents confirmed ongoing symptoms and discomfort. The facility's infection prevention and control program policy required surveillance, early detection, and control of communicable diseases, but these measures were not effectively carried out, resulting in the transmission of scabies among residents.