Deficiencies in Hand Hygiene During Meal Service and Lack of Water Management Program
Penalty
Summary
Staff failed to follow proper hand hygiene protocols during meal service on one of six halls reviewed. Specifically, a nursing assistant did not sanitize a serving cart after removing dirty breakfast trays before loading it with lunch trays, nor did she perform hand hygiene between delivering trays to residents, assisting with repositioning, or after leaving resident rooms. The staff member acknowledged not sanitizing her hands or the cart as required by facility policy, which mandates hand hygiene before and after resident contact, after touching objects in the resident's vicinity, and before and after handling food or assisting with meals. The Director of Nursing Services confirmed the expectation for staff to perform hand hygiene after each tray pass and to sanitize the meal cart before each use. Additionally, the facility did not have a developed or implemented water management program to address the risk of water-borne pathogens, such as Legionella, in the main water system. Although the facility had a Legionella Water Management Policy stating the need for annual review and risk assessment, there was no evidence of a risk assessment being completed as part of the facility's assessment. The administrator confirmed the absence of a water management program or prevention plan for water-borne pathogens in the facility's water system.