Failure to Maintain Hand Hygiene During Meal Service
Penalty
Summary
The facility failed to maintain appropriate hygiene practices during meal service in the 1st Floor dining room, as observed by surveyors. Nine staff members, including activity assistants, dietary aides, and medical record personnel, were present to assist with meal service. Despite the presence of hand hygiene resources such as alcohol-based hand sanitizer dispensers and a sink with soap and paper towels, several staff members did not perform hand hygiene at critical points during the meal service. Specifically, activity assistants were observed clearing used utensils, plates, and cups from tables, wiping tables, and placing dirty dishware in bins without wearing gloves or performing hand hygiene afterward. These same staff members then returned to serving food and beverages to residents without sanitizing their hands. Additionally, when serving ice cream from a communal container, the activity assistants did not perform hand hygiene before handling and distributing the items to residents. Interviews with staff and leadership confirmed that all staff had been trained on hand hygiene protocols and were aware of the importance of sanitizing hands between tasks, especially during meal service. The Director of Nursing and Infection Preventionist both stated that the expectation was for staff to use gloves when handling dirty items and to perform hand hygiene after glove removal or between serving residents. Despite this, the observed actions did not align with facility policy or training, resulting in a failure to prevent potential contamination and the spread of foodborne illnesses.