Failure to Provide Hand Hygiene Assistance During Meal Service
Penalty
Summary
During meal service, staff failed to follow proper infection control practices related to hand hygiene for three residents who required assistance with activities of daily living (ADLs), including personal hygiene. Facility policy required staff to perform hand hygiene before and after eating, but observations revealed that staff did not offer or provide hand hygiene assistance to these residents prior to their lunch meals. Specifically, staff brought meal trays, opened silverware, and allowed residents to begin eating without ensuring hand hygiene was performed. The residents involved had significant medical conditions and cognitive impairments, including pelvis fracture, chronic kidney disease, anemia, diabetes, anxiety, weakness, hemiplegia, chronic respiratory failure, and heart failure. Their care plans and Minimum Data Set (MDS) assessments indicated they were dependent on staff for personal hygiene. Interviews with staff and the Director of Nursing confirmed that hand hygiene assistance was not provided as required by facility policy during the observed meal service.