Failure to Implement Scabies Surveillance and Staff Notification Procedures
Penalty
Summary
The facility failed to follow its established surveillance plan for the prevention and control of scabies after a resident was diagnosed with the condition. The Infection Preventionist (IP) did not implement the required six-week contact identification list, instead conducting contact identification for only six days. Additionally, the IP did not assign a dedicated care team member to provide care for the affected resident, as specified in the facility's surveillance plan. The facility's policy required the development of a contact identification list for all individuals who may have had direct, physical contact with the case within the previous six weeks, but this was not completed. Key healthcare personnel, including staff from various departments such as environmental services and nursing, were not properly notified or trained on how to recognize and report signs and symptoms consistent with scabies infestation. The IP verbally notified only a limited group of staff during a huddle at the north station, and there was no documentation or sign-in sheet to confirm who attended. Many staff members, including CNAs, housekeepers, and nurses, reported that they were not informed of the scabies case through official channels and did not receive any in-service training or formal communication regarding the diagnosis or necessary precautions. The facility's records showed that no in-service training on scabies was provided after the diagnosis, and there was no documentation of communication or education in the resident's progress notes. The facility's surveillance plan and policy required prompt notification and education of all healthcare personnel and volunteers, as well as the assignment of a dedicated care team and the maintenance of a contact identification list for six weeks. These steps were not followed, resulting in a failure to implement the facility's own infection prevention and control procedures for scabies.