Failure to Implement Contact Isolation for Resident Treated for Suspected Scabies
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to the management of a resident being treated for suspected scabies. The resident, an older adult with dementia, Alzheimer’s disease, and lung cancer, had a scattered rash on both arms, chest, and stomach documented on 12/25/25, with some scabbing and no signs of itching. A physician note dated 1/13/26 documented that the rash was possibly scabies, with a plan to treat with permethrin cream and implement appropriate isolation. The Medication Administration Record for 01/2026 showed the resident received permethrin cream on 1/14/26 and 1/22/26 for a rash. However, review of the Physician Order Sheet from 12/21/25 to the present revealed no order for contact isolation related to rash or scabies, and the Infection Control Isolation Log for the last three months did not list the resident as having been on isolation. Staff interviews further demonstrated that isolation precautions were not implemented for this resident while being treated for suspected scabies. A CNA reported the resident had a rash on the arms, chest, and back a couple of months prior and stated that residents treated for scabies are supposed to be placed on isolation immediately, but the CNA was not aware this resident had been treated for scabies and denied ever seeing the resident on isolation, noting it was the nurse’s responsibility to enter isolation orders and inform staff. The former Wound Care Coordinator stated that when scabies is suspected, nurses contact the physician for orders and residents should be placed on contact isolation and moved to a private room because the condition is very contagious. The medical physician confirmed that residents treated with topical ointment for suspected scabies should have contact isolation ordered, and the DON stated that residents treated for scabies should be placed on isolation and moved to a room alone, but did not recall this resident being on isolation in the prior couple of months. The facility’s Infection Prevention and Control policy required provision of transmission-based precautions, including contact precautions with gown and glove use, when indicated, but these measures were not documented or implemented for this resident.
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