Improper Glove Use During Meal Service
Penalty
Summary
Staff failed to follow proper glove use practices during meal service, as observed in the Memory Care Unit. Nurse aides and a medication aide were seen donning gloves and then performing multiple tasks without changing gloves between tasks or after contact with potentially contaminated surfaces, residents, or items. Specific actions included handling residents' cups, pouring drinks, touching the rims of cups and plates, opening and closing cupboard doors, and handling a towel that had been in contact with a resident's body, all without changing gloves. Staff also touched food and food coverings, such as removing food covers and plastic wrap, and then directly handled residents' food and dessert bowls with the same gloves. Facility policy and CDC guidelines require hand hygiene before and after glove use and mandate changing gloves between tasks and after contact with contaminated surfaces or residents. Interviews with staff and the infection preventionist confirmed that gloves should have been changed to prevent cross-contamination, but this was not done during the observed meal service. These failures had the potential to affect all 15 residents in the Memory Care Unit.