Failure to Implement Head Lice Infection Control Policy and Timely Isolation
Penalty
Summary
The facility failed to implement its infection control guideline for head lice for one resident. On 11/6/25, the resident’s family member observed lice on the resident’s pillow at approximately 8:13 p.m. and reported this to staff, though the family member could not later identify which staff were notified. The resident, who had been admitted on 10/30/25 with a persistent vegetative state, chronic respiratory failure, and ventilator dependence, was under the care of CNA 1 and LVN 1 on that date. CNA 1 stated the complainant told her about the lice and showed her a picture on 11/6/25, but she could not remember if she reported this to a nurse or who the nurse was. LVN 1, who also worked with the resident on 11/6/25, stated he was not made aware of any lice by family or staff. The Infection Control Nurse (ICN) confirmed that she was not notified of the lice infestation on 11/6/25 and that the resident was not placed on isolation until 11/16/25, ten days after lice were initially observed. The ICN stated that facility interventions for lice include immediately placing the resident on contact isolation and notifying the physician, and there was no physician notification documented on 11/6/25. On 11/16/25, RN 1, who was working with the resident, received a complaint from the family about lice, assessed the resident, and noted lice, at which point the resident was placed on isolation. RN 1 reported he had not received any prior report indicating the resident had lice, although the complainant told him she had reported the issue to other staff previously. Review of the facility’s undated policy "INFECTION CONTROL GUIDELINE FOR PEOPLE WITH HEAD LICE" showed that patients with lice are to be placed in contact isolation, with gown and glove use, bagging of linens, and physician notification for treatment, measures that were not implemented when lice were first reported on 11/6/25.
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