Failure to Timely Report and Control Scabies Outbreak
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program when it did not timely report an initial confirmed case of scabies and subsequent cases to the Local Public Health Department (LPHD) and the California Department of Public Health (CDPH). The Infection Preventionist’s (IP) Scabies Case/Contact Line List documented the first confirmed resident case with onset on 12/25/25, followed by additional resident cases with onset dates of 1/9/26, 1/12/26, 1/14/26, 1/20/26, 1/21/26, 1/29/26, 1/30/26, and 2/1/26, all occurring in the short‑term unit. The IP stated she did not report the scabies incidents to the LPHD until 1/12/26 and did not report the outbreak to CDPH until 2/6/26, despite the first confirmed case having been identified in December. The Administrator confirmed that the facility experienced a scabies outbreak in the short‑term unit. The DON stated that the first case occurred on 12/25/25 and that no additional cases were identified until 1/9/26, and also reported that two staff members assigned to the affected unit tested positive for scabies. Review of the facility’s policies showed that an outbreak is defined as one case of a highly communicable infection or three or more cases of the same infection over a specified period in a defined area, and that the Administrator is responsible for communicating data about reportable diseases to the health department. Professional references from the California Department of Public Health and CDC indicated that scabies outbreaks in healthcare settings should be reported to the local health officer and CDPH, and that multiple cases in such settings constitute an outbreak for reporting purposes. Despite these policies and guidelines, the facility did not report the initial confirmed case when it was identified, which allowed ongoing transmission and resulted in a scabies outbreak affecting nine residents in the short‑term unit.
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