Failure to Perform Hand Hygiene During Meal Service
Penalty
Summary
During a dining observation in the facility's Front Dining Room, the Activity Director (AD) and Director of Staff Development (DSD) were observed serving and preparing food trays, as well as touching the shoulders and hands of six residents, without performing hand hygiene before and after direct contact with each resident. This occurred despite the facility's policy requiring hand hygiene before and after direct contact with residents, after contact with objects in the immediate vicinity of the resident, and before and after assisting a resident with meals. The AD and DSD both indicated during interviews that they were unaware of the requirement to perform hand hygiene between each resident during mealtime service. The residents involved had significant medical histories, including conditions such as cerebral infarction, diabetes, chronic kidney disease, congestive heart failure, muscle wasting and atrophy, benign prostatic hyperplasia, white matter disease, iron deficiency anemia, peripheral autonomic neuropathy, hypertension secondary to renal disorders, and cardiac arrhythmias. These conditions were documented in their admission records and highlight the vulnerability of the population affected by the deficient practice. Interviews with the Registered Nurse (RN), Infection Preventionist Nurse (IPN), and Director of Nurses (DON) confirmed that staff are expected to perform hand hygiene between residents during mealtime to prevent cross-contamination. The facility's policies and procedures, as reviewed, emphasize the importance of hand hygiene as the primary means to prevent the spread of infection and require all personnel to adhere to these procedures. The failure to follow these protocols was directly observed and acknowledged by staff, constituting a deficiency in the facility's infection prevention and control program.