Failure to Follow Infection Control Protocols During Food Tray Handling and PPE Use
Penalty
Summary
The facility failed to follow its infection prevention and control measures for three residents by not ensuring proper hand hygiene and use of personal protective equipment (PPE) by staff. Certified Nurse Assistant (CNA) 2 was observed exiting a resident's room after handling a dirty food tray without sanitizing hands and then proceeded to handle clean food trays for other residents without performing hand hygiene. Additionally, CNA 2 did not use alcohol-based hand rub before passing clean food trays to another CNA. CNA 1, who was responsible for setting up food trays in a room with a posted Novel Respiratory Precautions isolation sign, did not wear gloves or perform hand hygiene before accepting and setting up food trays for two residents who had been exposed to COVID-19. CNA 1 also failed to use hand sanitizer between setting up trays for the two residents. Both CNAs acknowledged during interviews that they did not follow proper hand hygiene protocols as required by facility policy. The residents involved had significant cognitive impairments and required assistance with activities of daily living, including eating. Facility policies reviewed indicated that staff were expected to adhere to hand hygiene and PPE protocols, especially when handling food trays and entering rooms with infection control precautions. The Infection Preventionist confirmed the importance of these measures during interviews.