Failure to Perform Hand Hygiene and Use Gloves During Meal Assistance
Penalty
Summary
A nursing assistant (NA) failed to perform proper hand hygiene and did not wear gloves while assisting a resident with meal set-up. The NA handled ketchup packets from the middle of the table, removed the top of the resident's hamburger bun, applied ketchup, and used the packet itself to spread the condiment before replacing the bun. The NA did not sanitize hands before or after assisting the resident, despite being expected to do so according to facility policy. The NA also confirmed during an interview that she did not follow the required hand hygiene or glove use protocols during this interaction. The resident involved had moderate cognitive impairment and required assistance with all activities of daily living, with multiple diagnoses including hypertension, neurogenic bladder, diabetes mellitus, arthritis, cerebral palsy, epilepsy, atrial fibrillation, and depression. Facility staff, including the infection preventionist and a registered nurse, confirmed that the expected practice was to wash hands and wear gloves when assisting residents with meals, and that using ketchup packets as utensils was inappropriate due to potential contamination. The facility's food handling policy also specified that food should not be touched with bare hands and that proper utensils and hand hygiene must be used.