Failure to Use PPE and Perform Proper Hand Hygiene During Resident Care and Meal Distribution
Penalty
Summary
Staff failed to use appropriate personal protective equipment (PPE) and perform proper hand hygiene in two separate instances. In the first instance, a Certified Nurse Assistant (CNA) entered the room of a resident who was on contact precautions without donning the required gown and gloves, despite clear signage and available PPE supplies at the room entrance. The CNA then exited the room with a breakfast tray, placing it in the food cart, and acknowledged during interview that proper PPE should have been worn. Facility policy required gloves and gowns to be worn upon entry into rooms under contact precautions, with hand hygiene performed before leaving the care environment. In the second instance, an LPN was observed distributing meals in the memory care unit dining room and directly handling residents' food items, such as spreading jelly on bread, without wearing gloves. The LPN performed hand hygiene between residents but did not use gloves while touching the food, contrary to facility policy and expectations. The Director of Nursing confirmed that gloves should be used when staff touch food items for residents. The LPN stated unfamiliarity with the unit and acknowledged the omission of glove use, despite having sanitized hands.