Failure to Perform Hand Hygiene During Meal Service
Penalty
Summary
Staff on the 3rd Floor Unit failed to adhere to infection control standards during lunch meal service. Four staff members, including two nurses and two CNAs, were observed removing meal trays from the meal truck and distributing them to residents without performing hand hygiene before or after entering resident rooms. Staff were seen entering rooms, handling bedside tables, and positioning trays for residents, then exiting rooms and continuing to distribute trays without using the alcohol-based hand sanitizer available in the hallway. Additionally, staff were observed handling both clean and dirty meal trays without performing hand hygiene in between, and one nurse was seen exiting a resident's room wearing gloves, which is against facility policy for hallway conduct. Interviews with staff confirmed that the expectation was to use alcohol-based hand sanitizer before entering and after exiting resident rooms, and that gloves should not be worn in the hallway. Staff acknowledged forgetting to perform hand hygiene and not following the established procedures. The Infection Control Nurse reiterated the facility's policy and expectations regarding hand hygiene and glove use, confirming that the observed practices did not align with infection prevention protocols.