Failure to Perform Hand Hygiene Between Residents During Feeding Assistance
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to perform proper hand hygiene while assisting with feeding a resident diagnosed with dementia who required maximum assistance with eating. The CNA was observed feeding the resident, then moving to assist another resident after performing hand hygiene, but subsequently returned to the first resident and resumed feeding without performing hand hygiene. This pattern was repeated, with the CNA alternating between residents and not consistently performing hand hygiene between each resident interaction as required by facility policy. The CNA acknowledged during the surveyor's intervention that she did not perform hand hygiene between residents, despite having received recent education on the subject and being aware of the policy. Interviews with the Director of Nursing (DON), Assistant Director of Nursing/Infection Preventionist (ADON/IP), and the Administrator confirmed that the CNA should have performed hand hygiene between each resident and that all staff had been educated on this requirement. The facility's policy on hand hygiene, which was reviewed, indicated that hand hygiene is required immediately before touching a resident and after contact with a resident or their environment. The failure to follow this protocol was directly observed and acknowledged by staff, constituting a breach in infection prevention and control practices.