Failure to Provide Hand Hygiene to Residents Before Meals
Penalty
Summary
The facility failed to implement an effective infection prevention and control program by not providing or offering hand hygiene to residents prior to meals in both the main and small restorative dining rooms. Observations over several days showed that staff prepared dining areas and served meals to groups of residents without ensuring that hand hygiene was performed. Staff members, including CNAs, acknowledged that they did not offer hand hygiene to residents before meals and confirmed that this practice was not routinely followed in the dining rooms. Some staff were aware of the importance of hand hygiene but did not implement it, and there was no system in place to verify if residents had cleaned their hands before eating. Interviews with staff, including the Infection Control Nurse and the Director of Nursing, revealed that while staff were trained on hand hygiene practices, there was no consistent process to ensure residents received hand hygiene before meals. The facility's hand hygiene policy specified that staff should wash their hands before and after eating but did not clarify when or how hand hygiene should be offered to residents. This lack of a clear system and consistent practice affected approximately 25 residents in the main dining room at lunch, 10 at dinner, and 10 in the small restorative dining room at lunch each day.