Failure to Assess, Treat, and Communicate Generalized Rash Leading to Scabies Diagnosis
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to recognize and respond to a change of condition related to a resident’s generalized itchy rash, to provide treatment, and to communicate this condition to the receiving hospital. The resident, who had diagnoses including schizophrenia, cardiomegaly, and chronic kidney disease and whose H&P noted fluctuating capacity to understand and make decisions, was readmitted to the facility with generalized itchy rashes over the whole body. A progress note dated 1/10/2026 documented the readmission with generalized itchy rashes, and a skin check on the same date recorded a rash on the abdomen, cervical region, and bilateral front and back thighs, marked as a new issue to be tracked. Despite this documentation, no Change of Condition (COC) form was initiated, and the physician was not notified as required by facility policy. Subsequent documentation and interviews showed that the rash continued without appropriate assessment or treatment. A multidisciplinary care conference (IDT) dated 1/13/2026 contained no indication of the rash or any medical treatment for the generalized itching. A follow-up skin check dated 1/15/2026 again documented the rash in the same areas and indicated it should be tracked and reviewed, yet the resident was not monitored for the rash between 1/11/2026 and 1/15/2026, and no treatment was initiated. The Treatment Nurse stated that the situation represented a COC and that the physician should have been notified so medical treatment could be started, and also acknowledged that staff would not know if the rash was improving or worsening due to lack of monitoring. The Infection Preventionist similarly stated that the resident should have been treated prophylactically and that there was no COC, no monitoring for symptoms, and no treatment for itching. When the resident was transferred to a General Acute Care Hospital on 1/15/2026, the facility’s discharge summary (SNF/NF to Hospital Transfer Form) indicated that the resident had no skin issues, despite prior documentation of a generalized rash. Hospital records from the same date documented a generalized rash over the whole body, and by 1/17/2026 the hospital had placed the resident on isolation precautions for scabies. The Treatment Nurse and a Registered Nurse both stated that licensed staff were expected to provide a complete report to the hospital, including skin conditions, and acknowledged that the rash was not communicated, characterizing this as poor communication. Facility policies on Prevention and Management of Scabies required examination for signs and symptoms of scabies on admission, isolation of undiagnosed and untreated rashes, and notification of the DON for suspicious rashes, while the Change of Conditions policy required physician notification, assessment, SBAR communication, and documentation every 72 hours for significant changes. These policy requirements were not followed in the resident’s case.
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