Failure to Follow Hand Hygiene Protocols During Meal Service
Penalty
Summary
Staff failed to consistently observe required hand hygiene practices during meal service, as evidenced by multiple direct observations. The Admission Coordinator (AC) was seen touching various surfaces, including meal tickets, a pen, and a food cart, without performing hand hygiene before serving plates of food to residents. The AC served food to several tables before using hand sanitizer. Additionally, a Dietary Aide (DA1) was observed touching her hair and clothing with gloved hands, picking up a cup lid from the floor and placing it in her pocket, all without changing gloves or performing hand hygiene. These actions were in direct contradiction to the facility's infection prevention and hand hygiene policies, which require hand hygiene before and after food service, and glove changes after contact with potentially contaminated surfaces. Interviews with staff and management revealed inconsistent understanding and application of hand hygiene protocols. The AC believed hand hygiene was only necessary after serving all residents at a table, while the Dietary Manager and other leaders stated that hand hygiene should occur between each plate or tray served, and gloves should be changed after touching contaminated surfaces. Despite these stated expectations, observed practices did not align with facility policy or management guidance, resulting in a failure to maintain proper infection control during food service for all residents receiving meals from the kitchen.