Failure to Perform Hand Hygiene and Use PPE During Meal Service
Penalty
Summary
The facility failed to adhere to its infection prevention and control policies during meal tray distribution, as evidenced by multiple staff omissions in hand hygiene and use of personal protective equipment (PPE). Specifically, the Assistant Director of Nursing (ADON) delivered and set up lunch meal trays for three residents without performing hand hygiene after each interaction, despite facility policy requiring hand hygiene between resident contacts. These residents had varying degrees of cognitive and physical impairment, with some requiring setup or clean-up assistance with eating and personal hygiene. Additionally, the ADON failed to don appropriate PPE when delivering a meal tray to a resident who was on contact isolation, contrary to the facility's transmission-based precautions policy. The resident in question required setup assistance with eating and partial to moderate assistance with personal hygiene. The ADON acknowledged not wearing the required PPE before entering the room, despite being aware of the resident's isolation status. Furthermore, a Licensed Practical Nurse (LPN) did not offer hand hygiene assistance to a resident who was dependent on staff for personal hygiene prior to serving the lunch meal. This omission was confirmed by the LPN during an interview. Both the Infection Preventionist and the Director of Nursing confirmed that staff are expected to perform hand hygiene before and after delivering meal trays, don appropriate PPE for residents on contact isolation, and offer hand hygiene assistance to all residents prior to meals.