Failure to Implement Infection Control Measures for Lice Infestation
Penalty
Summary
The facility failed to follow proper infection control procedures for a resident who was identified with pediculosis (lice). Upon admission, the resident complained of an itchy scalp and was found to have head lice, for which treatment with permethrin 1% shampoo was ordered and administered. Despite this, the facility did not initiate contact precautions or isolation measures as required by CDC guidelines, and there was no documentation that the resident’s former or new roommates were assessed, screened, or monitored for lice during or after the room change. Both licensed nurses involved confirmed that contact precautions were not implemented and that there was no evidence of monitoring or assessment of the roommates for lice. The Director of Nursing acknowledged that the facility did not follow its own policy or CDC recommendations, which require contact precautions for at least 24 hours after initiation of effective therapy for lice. The DON also confirmed that no monitoring of roommates occurred during the resident’s room transfer and that a sign for precautions was not placed on the door. The facility’s policy indicated that the interdisciplinary team should implement measures to eliminate infestation and prevent spread, but these steps were not documented or carried out in this instance.