Failure to Report Suspected Scabies Outbreak to CDPH
Penalty
Summary
The facility failed to report a suspected scabies outbreak involving three residents to the California Department of Public Health (CDPH) as required. Record reviews showed that all three residents had severe cognitive impairment and were dependent on staff for hygiene and bathing. Physician orders for these residents included the administration of Permethrin cream and Ivermectin for suspected or suspicious scabies, indicating clinical suspicion of an outbreak. Despite these findings, there was no evidence that the facility reported the suspected outbreak to CDPH within the required timeframe. Interviews revealed that the Infection Prevention Nurse was unaware of the requirement to report a suspected scabies outbreak to CDPH. The Director of Nursing stated that the IP nurse believed the Public Health Nurse would make the report, which led to the failure to notify CDPH. A review of the facility's policy indicated that outbreaks of communicable diseases must be reported to the appropriate agency within 24 hours, but this protocol was not followed in this instance.