F0880

E

Failure to Implement Scabies Outbreak Control, Skin Assessment, and Reporting Procedures

Burbank, California Survey Completed on 02-21-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement and follow its infection prevention and control program, skin assessment policies, and communicable disease reporting procedures during a scabies outbreak. One resident was readmitted with documented rashes on the chest and abdomen, but weekly Skin Rash Reports were not initiated or completed after the readmission, despite facility policies requiring weekly skin inspections and documentation of non‑pressure skin conditions and rashes. Treatment nurses and other nursing staff acknowledged that weekly rash assessments were not performed or documented on multiple Thursdays, and the Minimum Data Set nurse and Resident Nursing Supervisor confirmed that the facility’s policies on Prevention of Pressure Injuries/Skin Breakdown, Body Checks, and Alteration in Skin Integrity were not followed. Staff stated that without weekly rash documentation, the progress of the rash and effectiveness of treatment could not be evaluated, and that the resident’s rashes could worsen.

The facility also failed to notify the wound care provider and dermatologist and to document key clinical information related to the scabies outbreak. After the resident’s readmission with rashes, there was no documentation that the wound care physician or nurse practitioner was informed, and no subsequent wound care notes were found. The nurse practitioner, infection preventionist, MDS nurse, RN, and Resident Nursing Supervisor all stated that the wound care provider should have been notified and that there was no documentation of such notification. Although there was an order and care plan intervention for a dermatology consult, treatment nurses did not ensure that the dermatologist who visited on two separate dates was informed of this resident’s rashes, and the dermatologist’s progress notes showed that only nine other residents were evaluated and treated. The administrator and infection preventionist stated that the dermatologist should have been notified of all residents with rashes, including this resident. Additionally, when the facility was notified by an outside hospital that this resident tested positive for scabies, the marketer relayed the information verbally to the administrator, but there was no documentation of this notification in the resident’s medical record, contrary to the facility’s Charting and Documentation policy requiring complete and accurate documentation.

The facility did not properly recognize and report the scabies outbreak to the State Survey Agency and did not complete required surveillance and assessments for exposed residents and staff. One resident had previously tested positive for scabies at another hospital, and the infection preventionist stated the facility was informed of this result. When a second resident later tested positive for scabies at a different hospital, the administrator acknowledged being notified but did not report this second confirmed case to the State Survey Agency, despite facility policies and county guidelines defining an outbreak as two or more cases and requiring reporting within 24 hours. The administrator later acknowledged that the facility’s Scabies: Prevention and Control policy and Unusual Occurrences policy were not followed. The infection preventionist and Resident Nursing Supervisor confirmed that the facility was considered to be in a scabies outbreak and that such outbreaks should be reported. The facility also failed to perform and document daily skin assessments on four residents who were identified as exposed through room sharing and dining contact, despite facility guidelines and policies requiring daily skin assessments on exposed residents and daily assessments for roommates of infected residents until the case was resolved.

The deficiency further includes failures related to staff training, competency, and case tracking. The Director of Staff Development/Infection Preventionist and Resident Nursing Supervisor stated that no in‑service education, training, or competency evaluation on skin scraping was provided to the treatment nurses before they performed skin scrapings on residents during the outbreak. They acknowledged that the nurses were not checked for competency and that training should have been done before skin scraping procedures were carried out. Additionally, a certified nursing assistant who developed lower back rashes was treated with Elimite cream but was not assessed for scabies via skin scraping, and the facility did not develop a line list identifying this staff member’s resident contacts for the six weeks prior to symptom onset, as required by the facility’s submitted Acute Communicable Disease Control Program–Scabies Prevention and Control Guidelines. These guidelines also required preparation of line lists for symptomatic healthcare workers and residents and daily skin assessment documentation on all exposed residents, which the facility did not complete.