Failure to Perform Hand Hygiene During Meal Service
Penalty
Summary
Staff failed to perform proper hand hygiene during meal service, as observed when the Activities Director delivered breakfast trays to six residents without washing or sanitizing hands between rooms or after touching potentially contaminated surfaces. The Activities Director also handled food items, such as buttering and applying jelly to toast with bare hands, and touched residents directly without using gloves. These actions were observed during a single meal service and involved multiple instances of moving between residents and handling both food and residents without appropriate hand hygiene. Interviews with the Activities Director, a CNA, the Director of Operations, and the Administrator confirmed that staff should have washed or sanitized their hands between residents and used gloves when directly handling food. Facility policy review indicated that all staff are required to comply with CDC hand hygiene guidelines, including performing hand hygiene before direct contact with residents. The deficiency was identified during a complaint investigation and affected six residents out of those reviewed for handwashing.