Failure to Follow Infection Control Protocol During Tray Line Service
Penalty
Summary
A deficiency was identified when a dietary aide was observed coughing multiple times over residents' lunch trays on the D Unit tray line without stepping back, sanitizing, or washing her hands. Although the aide coughed into her elbow as trained, she did not follow the facility's hand hygiene policy, which requires hand washing after coughing. This practice had the potential to affect all residents on the D Unit, which had a census of 20 at the time. The aide later reported she had allergies and had been trained to cough into her elbow, but did not mention any additional hand hygiene measures following the coughs. Interviews with facility staff, including the dietary manager, infection preventionist, DON, and administrator, confirmed that the expected protocol was for staff to step away from the tray line, sanitize or wash hands after coughing, and, if coughing persisted, to be removed from the tray line or wear a mask. The facility's policies on personal hygiene and hand washing were not followed during the incident, resulting in a failure to maintain an effective infection prevention and control program as required.