Failure to Prevent and Control Scabies Outbreak Among Residents
Penalty
Summary
The facility failed to prevent the spread of a rash, later identified as scabies in multiple cases, among residents across different rooms, halls, and floors. Multiple residents developed rashes over several months, with initial cases appearing as early as July. Despite the presence of rashes and ongoing symptoms, the facility did not implement transmission-based precautions or isolation measures until after a confirmed diagnosis of scabies was received for one resident in mid-November. Prior to this, residents were treated with various medications, including antihistamines, steroids, antifungals, and antiparasitics, but there was no coordinated infection control response or consistent use of personal protective equipment (PPE) by staff. Medical records and interviews revealed that residents with cognitive impairments and complex medical histories, such as Alzheimer's disease, dementia, and stroke, were affected. Several residents had persistent or worsening rashes, and some were transferred to other facilities with active symptoms. Staff interviews indicated confusion and inconsistency in the approach to the rash, with some staff believing it was an allergic reaction and others suspecting a viral cause. Housekeeping staff reported not receiving special cleaning instructions or being informed of isolation protocols until well after the outbreak had spread. The facility's infection prevention and control policies required surveillance and the use of standard and transmission-based precautions for communicable diseases. However, these measures were not implemented in a timely manner. The infection preventionist and other staff confirmed that isolation, PPE use, and enhanced cleaning only began after a scabies diagnosis was confirmed, despite the rash affecting numerous residents and staff over several months. Documentation showed a significant increase in cases in November, with at least 28 residents affected by that time.