Failure to Implement Scabies Infection Control Measures After Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, including infection tracking, contact tracing, and environmental precautions, for a resident with a presumptive diagnosis of scabies. The resident was admitted with diagnoses including paranoid schizophrenia and unspecified convulsions and had a care plan problem for a rash on multiple body areas related to allergies, eczema, and psoriasis. During a subsequent hospital stay, the resident developed a diffuse pruritic rash resembling scabies and was treated with permethrin cream and placed in contact isolation due to a history of MRSA and the current rash. The hospital transfer orders back to the facility documented contact isolation status and possible scabies. On readmission, nursing notes described a generalized rash, but the RN who readmitted the resident did not review the hospital discharge or transfer paperwork, did not obtain a verbal report from the hospital, and was therefore unaware of the scabies diagnosis and treatment. As a result, the resident’s scabies diagnosis and treatment were not entered into the facility’s March infection control log, and no follow-up skin checks or contact tracing were conducted to determine if other residents were affected. The infection control nurse stated she did not log the case because the diagnosis and treatment occurred at the hospital rather than in the facility. Housekeeping/laundry staff reported they had not been notified of any scabies cases or the need for isolation-level room cleaning or laundry processing, and the APN stated she was not informed of the hospital’s scabies treatment until the survey date. The facility’s own scabies control policy requires inspection of residents who had contact with the affected resident, assessment by the DON and infection control nurse to determine preventive measures, bagging and hot washing of linens and clothing, thorough environmental cleaning and disinfection of furniture and equipment, and simultaneous treatment of affected individuals. None of these specified infection control measures were implemented for this resident upon return to the facility, despite documented possible scabies and contact isolation orders from the hospital.
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