F0880

D

Failure to Implement Scabies Treatment and Contact Precautions

Palm Springs, California Survey Completed on 02-09-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement ordered and recommended infection control interventions and treatment for a cognitively intact resident with suspected and later diagnosed scabies. The resident, admitted with hemiplegia following a stroke and scoring 13 on the BIMS, was noted on November 17, 2025, to have self-inflicted scratches and a rash on the chest and arms. On the same date, a dermatology visit documented an impression of scabies with linear burrows and a plan to treat with Permethrin 5% cream applied from neck to toes overnight and repeated in one week. The dermatology note also stated that scabies is very contagious and that household contacts should be treated, and contaminated clothing isolated and laundered appropriately. However, after this consultation, no physician order for Permethrin was entered, and the November 2025 TAR showed that Permethrin was not administered.

On November 26, 2025, a physician order was written to “scrap” for scabies, but this order was discontinued later the same day without the procedure being completed and without any documentation explaining the discontinuation. The Infection Prevention Nurse (IP) confirmed that there were no skin scraping results for November 2025 and that she did not know why the order was discontinued, as it was not communicated to her and there was no nursing documentation. The DON similarly verified that no skin scraping was performed, that the order was discontinued without explanation, and that there were no results in the record, despite the facility policy stating that a diagnosis is made via physical exam and/or skin scrapings with microscopic exam.

On December 1, 2025, the resident had a follow-up dermatology consultation again documenting an impression of scabies with linear burrows and the same plan for Permethrin 5% cream treatment and repeat in one week. A physician order for Permethrin was entered on December 1, 2025, but was discontinued twice on the same date, and the December 2025 MAR showed that the treatment was not administered or repeated one week later. There was no documentation in the progress notes explaining why the Permethrin treatment was discontinued or not given. Although a physician order for contact isolation for a diagnosis of scabies was written on December 17, 2025, the IP and DON confirmed that after both dermatology consultations, the facility did not implement contact isolation precautions, did not perform the ordered skin scraping, did not prophylactically treat the resident’s roommates, and did not initiate a close contact list, contrary to the facility’s communicable disease policy that required immediate containment, treatment, use of contact precautions, simultaneous treatment of roommates, and documentation of treatments and monitoring.