F0684

E

Failure to Timely Identify, Test, and Communicate Scabies Cases and Exposures

Burbank, California Survey Completed on 01-28-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow its own scabies identification and control policies and professional standards of practice for multiple residents with rashes and pruritus. One resident with a history of dermatitis, diabetes mellitus type 2, and Parkinson’s disease was admitted and later readmitted with progressively spreading rashes on the chest, bilateral upper and lower extremities, back, and abdomen. The resident’s care plan for skin integrity noted a skin rash and included interventions such as administering treatment as ordered and notifying dermatology for non-response. Over several months, skin rash reports documented complaints of itchiness on multiple dates, but there was no documented evidence that a skin scraping was performed or that a dermatologist was consulted, despite staff acknowledging that skin scraping is used to confirm scabies and that the facility had a scabies policy describing diagnostic procedures. The resident was eventually transferred to an acute care hospital for altered mental status and abnormal vital signs, with documentation noting a body rash, and a subsequent scabies examination on a later date showed a positive result for scabies.

After the positive scabies result for this resident, the facility did not promptly or comprehensively identify and assess all exposed residents and staff as required by its scabies policy and the referenced Acute Communicable Disease Control (ACDC) guidelines. The Director of Staff Development (DSD) produced a new Scabies Case Contact Line List that initially included only the resident and two roommates, with no documented assessments of other exposed residents. The DSD later stated that residents who sat beside the affected resident in the dining room were only added to the line list several days after the facility became aware of the positive scabies result, and the Director of Nursing (DON) acknowledged that residents exposed in the dining room were not assessed after the positive test. Another cognitively impaired resident who attended the same dining room and activities and was identified as exposed was not assessed for scabies, and there was no documentation of assessments for other contacts beyond roommates and later-identified dining companions.

The facility also failed to ensure timely and appropriate diagnostic testing and treatment sequencing for the roommate with generalized rashes. This roommate was admitted without documented skin issues, but a skin reassessment the following day showed rashes on bilateral upper and lower extremities, chest, and back. The care plan identified skin rash with interventions to administer treatment as ordered and notify dermatology of non-response. Physician orders later directed prophylactic permethrin cream application and contact isolation for possible exposure to rashes, and the medication administration record showed the permethrin was given. However, staff interviews and record review revealed that a skin scraping for this resident was ordered and performed only after the permethrin treatment had already been administered, and there was no documented evidence that a dermatologist had assessed this resident or that a skin scraping was done prior to treatment. During observation, this resident was noted to have extensive pruritic rashes in classic scabies distribution, and a CNA was seen in the room under enhanced barrier precautions without wearing PPE while touching room surfaces.

Communication failures compounded these issues, as several staff members who provided direct care to the resident with confirmed scabies were not promptly informed of the positive result. A treatment nurse, a CNA, and an LVN each reported that they were not notified of the positive scabies diagnosis until two to four days after the facility became aware of it, despite having been assigned to care for the resident and having observed or managed the resident’s itching and rashes. The DSD stated she did not know if staff who cared for the resident before the positive test were notified, and the nurse practitioner reported that he was not informed of the positive scabies result. The nurse practitioner also stated that he received pushback from facility management, including the administrator, DON, and infection preventionist, when he raised concerns about ordering skin scrapings for residents with rashes, and that management expressed concern that positive scabies findings could trigger an outbreak designation and fines. The DON acknowledged that the facility had not had a dermatologist for two years, that they waited for dermatology services to determine which residents needed skin scraping, and that the facility failed to consider timely skin scraping tests and assessments for residents exposed to the confirmed scabies case.

The facility’s own scabies policy and the ACDC guidelines it referenced required careful examination of roommates of infected residents, daily assessments of asymptomatic exposed residents, prompt evaluation of patients on affected units, immediate placement of suspected cases on contact precautions, preparation of line lists of symptomatic residents and their contacts, evaluation of contacts, and provision of prophylactic treatment to contacts within a short time frame. Despite these written procedures, the survey findings showed that only limited contact tracing and delayed listing of dining room contacts occurred, that not all exposed residents were assessed, that diagnostic skin scrapings were delayed or not performed for symptomatic residents, and that staff and practitioners were not promptly informed of a confirmed scabies case. Staff interviews, observations, and record reviews consistently demonstrated gaps between the written policies and the actual practices related to scabies identification, testing, communication, and contact management.