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Based on interview and record review, the hospital failed to ensure the nursing staff implemented its P&P for managing head lice for one of four sampled patients (Patient 3) by not performing an admission assessment for lice, not reassessing Patient 3 within 24 hours after treatment, and not notifying the physician to discontinue isolation. As a result, Patient 3 remained in isolation unnecessarily, missing the Halloween celebration and multiple group therapy sessions, which negatively impacted socialization and contributed to feelings of withdrawal, depression, and anxiety.

Findings:

During a review of the hospital's P&P titled Scabies or Pediculosis Management dated October 2025, the P&P showed all patient will be assessed for lice and scabies on admission. Any patient with suspected or confirmed pediculosis or scabies shall be placed on Contact Precautions automatically and reported to unit director and Infection Control Department for appropriate follow up. The patient should be placed in contact isolation until 24 hours after appropriate treatment, preferably in private room; and instructed to take a bath or shower after applying the medication according to the Manufacturer Recommendations.

Review of the Elimite: Package Insert/Prescribing Info showed Elimite (permethrin) 5% cream is a topical scabicidal agent for the treatment of infestation with scabies. The Elimite Dosage and Administration section showed to thoroughly massage Elimite 5% cream into the skin from the head to the soles of the feet; the cream should be removed by washing (shower or bath) after eight to 14 hours; one application is generally curative.

During a review of Patient 3's medical record on 12/15/25 at 0900 hours, with the Director of Performance Improvement and Risk Management and Nurse Managers 1 and 2, Patient 3's medical record showed Patient 3 was admitted to the hospital on 10/29/25, for suicidal and danger to self and discharged on 11/1/25.

During a review of the Nurse Admission Assessment dated 10/29/25 from 1325 hours to 1340 hours, the Nurse Admission Assessment did not include the head lice assessment for Patient 3.

During the review of the Group Note dated 10/30/25 from 1600 to 1700 hours, the Group Note showed Patient 3 actively participated in gym groups including basketball, volleyball, soccer, and yoga. Patient 3 interacted appropriately with peers and did not require verbal redirection. Patient 3 demonstrated an understanding of the group's purpose by engaging with sports equipment and participating in activities.

Review of the Group Note dated 10/30/25 from 1700 to 1800 hours, showed Patient 3 actively participated in a one-on-one quiz, discussions and group information about treatment and goals, acknowledged the benefits of attending therapeutic groups, coping skills, ADLs, meeting with therapists/psychiatrists, and collecting prizes and stamps.

During a review of the Order dated 10/30/25 at 1622 hours, the Order showed the order for permethrin (same as Elimite) external 1% lotion, external use once for the treatment of lice, one bottle for one application.

During a review of the nurse's Progress Note dated 10/30/25 at 1912 hours, the Progress Note showed patient's family member was informed Patient 3 was found to have head lice, one time treatment was ordered by the physician and completed. Patient 3 was placed on isolation precautions per facility protocol.

During a review of the Psychiatric Progress Note dated 10/31/25 at 0900 hours, the Psychiatric Progress Note showed Patient 3 was withdrawn and isolated due to having lice. Patient 3 reported depression and anxiety and was unable to contract for safety.

During the review of the Group Notes dated 10/31/25, the Group Notes showed the following:

* From 0930 to 1030 hours, Patient 3 could not attend the group session due to isolation precautions. The therapist provided Patient 3 with the group workout.

* From 1100 to 1200 hours, Patient 3 was on room restriction for active lice infection and given activities to work instead of group activities.

* From 1330 to 1430 hours, Patient 3 could not join in group session due to contact precautions. Patient 3 met one on one to discuss the benefits of group participation, provided supplemental materials, and educated the benefits of participating in future groups.

* From 1500 to 1600 hours, Patient 3 missed the group session due to isolation precautions. The therapist attempted to meet one-on-one to discuss friendships and healthy versus unhealthy boundaries.

* From 1600 to 1700 hours, Patient 3 was on isolation due to an active lice infection and received treats and prizes from the Halloween party.

* From 1700 to 1800 hours, Patient 3's behavior showed a calm effect upon approach. Patient 3 refused discussion on the benefits of attending therapeutic group, coping skills, ADL, and meeting with therapists/ psychiatrists stating "no."

During a review of the Discharge Summary dated 11/4/25 at 0746 hours, the Discharge Summary showed Patient 3 was assessed on 11/1/25 at 1000 hours. Patient 3 was isolated to room due to lice and received group therapy paperwork. Patient 3 was stable with an improved mood, no signs of irritability or dangerousness, better sleep, motivated to get better, and satisfaction with the aftercare plan. Patient 3 could benefit from further hospitalization. Patient 1's family member wanted to take patient AMA due to isolation.

During a telephone interview with the IP on 12/15/25 at 1055 hours, the IP stated Patient 3 had head lice and was placed on contact isolation. The treatment followed manufacturer's recommendations. The IP stated Patient 3 was instructed to shower after treatment and the linen and room were cleaned. Patient 3 was checked within 12 to 24 hours. Isolation could continue beyond 24 hours if necessary and if Patient 3 was not clear. The nurse could notify the physician to get the verbal order to discontinue the isolation.

During an interview with the Therapist with the present of the Director of Performance Improvement and Risk Management and Nurse Managers 1 and 2 on 12/15/25 at 1130 hours, the Therapist stated she helped with morning and afternoon group therapy for seven hours. The Therapist stated when patients were in contact isolation, the therapist would not go into patient's room, but meet patients at their door to provide activities schedule, group worksheet and drawings. Discontinuation of isolation was discussed every morning in the treatment team meetings.

During an interview with the Director of Performance Improvement and Risk Management, Nurse Manager 1 and 2 on 12/15/25 at 1138 hours, the Director of Performance Improvement and Risk Management confirmed no head lice assessment was conducted on admission and 24 hours post treatment to clear the patient from isolation. The Director of Risk Management confirmed the nurse did not inform the physician to discontinue isolation as per their P&P, causing Patient 3 to miss the Halloween celebration and group sessions.