Deficiencies in Hand Hygiene, PPE Use, and Sanitary Practices During Meal Service
Penalty
Summary
The facility failed to provide hand hygiene assistance prior to meals for three residents on one of four units observed during meal tray distribution. Specifically, staff delivered meal trays to residents who required assistance or supervision with activities of daily living, including eating and personal hygiene, without offering hand sanitizer or assisting them to wash their hands. Staff interviews confirmed that hand hygiene should have been offered, but was not provided to these residents before meals. Additionally, the facility did not ensure proper use of Personal Protective Equipment (PPE) for a resident on Enhanced Barrier Precautions (EBP) due to a feeding tube. During a high-contact care activity involving the management of a feeding tube, a registered nurse wore gloves but did not don a gown as required by facility policy and posted signage. There was also a lack of appropriate signage indicating the need for EBP at the time of the observation, and staff were not initially aware of the correct PPE requirements for this resident. The facility also failed to maintain sanitary conditions during meal service related to the handling and storage of the ice scoop used for resident drinks. A certified nursing assistant placed the ice scoop directly into the ice storage container instead of the designated holder, preventing the container lid from closing and exposing the ice to potential contamination. Staff interviews confirmed the improper storage of the ice scoop and acknowledged the failure to follow facility procedures for maintaining a sanitary environment.