Improper Hand Hygiene During Beverage Service
Penalty
Summary
The facility failed to ensure food was distributed and served in accordance with professional standards for food service safety during a recertification survey. The Assistant Director of Nursing was observed serving beverages to multiple residents in the main dining room without performing proper hand hygiene. The staff member wore disposable gloves while serving but did not change them between serving different residents. Additionally, the Assistant Director of Nursing touched various surfaces, such as the beverage cart handle and a resident's walker, without changing gloves or sanitizing hands, and continued to serve beverages to residents. The Assistant Director of Nursing also touched their own face with bare hands while taking a beverage order and proceeded to serve a resident without washing or sanitizing hands. The staff member admitted to wearing gloves to prevent contamination of the ice but acknowledged that gloves were not necessary and that hand hygiene should have been performed. The surveyor confirmed that the sink was out of soap, which contributed to the lack of proper hand hygiene during the beverage service.
Plan Of Correction
Plan of Correction: Approved April 4, 2025 Resident # 93 had no ill effects from the deficient practice noted during the meal service on 3/5/25. The resident was monitored for 5 consecutive days for any emotional distress with no issues noted. The resident’s care plan was reviewed and is in concert with the resident’s current needs and a medical record review completed with no abnormal findings. ADON was educated on proper hand hygiene while serving in the main dining room. She has since been re-audited and successfully redemonstrated understanding. All facility residents have the potential to be affected by the alleged practices. A meal service audit was conducted on all units to verify that disposable gloves were not being used during meal pass and that hand hygiene was performed properly. No further issues were identified. All nursing staff will be in-serviced regarding proper hand hygiene in accordance with professional standards for food service safety while serving meals. Weekly audits will be completed across all 3 meals in each dining room on a rotating basis by DON/designee to assure proper hand hygiene during meal service. Audits will continue until 100% compliance is attained for 4 consecutive weeks. The DON/ADON will review audits for compliance. Any negative findings will result in immediate education. The audit results will be reported at the monthly QAPI meeting. The frequency of ongoing audits will be determined by the QAPI committee based on audit results. The person responsible for the corrective action is the Director of Nursing/designee. Date of Compliance is 4/18/25.