Failure to Perform Hand Hygiene During Meal Service
Penalty
Summary
A Certified Nurse Assistant (CNA) failed to perform hand hygiene during meal service for 18 residents. The CNA was observed repeatedly touching her hair, face, glasses, nose, clothing, and cellular phone with bare hands, and then serving coffee, passing meal trays, and assisting residents with their meals without using hand hygiene at any point during the entire meal service. The alcohol-based hand rub dispenser was operational and available at the kitchen opening, but was not used by the CNA. Interviews with other CNAs indicated that they were aware of the requirement to perform hand hygiene after touching hair, clothes, or cell phones and before and after assisting residents with meals. The facility's hand hygiene policy also documented the need for hand hygiene after contact with objects in the resident's vicinity and before and after assisting with meals. Despite this, the observed CNA did not follow these protocols, resulting in a failure to implement the infection prevention and control program as required.