Failure to Isolate Resident with Confirmed Scabies Diagnosis
Penalty
Summary
The facility failed to implement effective infection prevention and control measures when a resident with a confirmed diagnosis of scabies was placed in the same room as another resident without a documented diagnosis of scabies. Despite the confirmed scabies diagnosis, the resident was transferred into a shared room on the same day the diagnosis was received, and there was no evidence of appropriate isolation or care planning for scabies or rash for either resident. Documentation revealed that the care plans for both residents did not include goals, focus, or interventions related to scabies, contact dermatitis, or rash, and there was no indication that the facility had systematically addressed the risk of transmission between roommates. Multiple records, including nursing notes, medication administration records, and care plans, showed that both residents received treatments such as Permethrin and Ivermectin for rashes and suspected scabies over several months. However, the infection control mapping and documentation did not consistently identify all affected residents, and the facility's infection preventionist relied on color-coded maps that omitted at least one resident with a documented rash and scabies treatment. Interviews with staff revealed inconsistent awareness and understanding of the scabies cases, with some staff attributing rashes to non-infectious causes and others reporting ongoing concerns about rash transmission and inadequate infection control measures. Observations and interviews further confirmed that the two residents were sharing a room while one was under contact isolation precautions for scabies. Staff interviews indicated a lack of clear communication and documentation regarding scabies diagnoses and infection control protocols. The facility's own infection control policy and CDC guidelines require isolation and specific precautions for scabies, but these were not consistently implemented or documented for the residents involved.