Failure to Perform Hand Hygiene During Meal Assistance
Penalty
Summary
Certified Nurse Assistants (CNAs) failed to perform proper hand hygiene before and during the process of assisting dependent residents with eating and while serving drinks. Observations revealed that a CNA alternated between assisting two residents with eating, touching their faces, hands, and utensils without performing hand hygiene at any point. Another CNA was observed assisting two residents with eating and handling their glasses by the rim, as well as touching the table and residents, again without performing hand hygiene. These actions were directly observed during mealtimes, and the staff involved acknowledged not performing hand hygiene, citing forgetfulness and lack of hand sanitizer. The residents involved had significant medical and cognitive impairments, including critical illness myopathy, traumatic brain injury, dementia, Parkinson's disease, and dysphagia, requiring varying levels of assistance with eating. Care plans for these residents documented their dependence on staff for eating and supervision. Interviews with residents and staff confirmed that hand hygiene was not performed between assisting different residents, and the facility's policy required hand hygiene before direct contact with residents. The Dietary Manager also stated that staff should not grab cups by the top where residents drink from.