Failure to Perform Hand Hygiene During Meal Service
Penalty
Summary
A certified nursing assistant (CNA) failed to perform proper hand hygiene while serving and assisting residents with their meals in the facility's only dining room. During observation, the CNA was seen carrying meal trays from the kitchen cart to residents and assisting them by setting up trays, unwrapping utensils, and opening drinks, without using hand hygiene between each tray passed. The CNA admitted during an interview that he had passed four trays without performing hand hygiene, despite having received training on the importance of hand hygiene between each tray. He acknowledged that this practice was not acceptable and could lead to cross contamination and illness among residents, particularly those who are older and more vulnerable. The Director of Nursing (DON) and the Administrator (ADM) both confirmed their expectations that staff should sanitize their hands before and in between passing trays, either by washing hands or using hand sanitizer. Both expressed concerns about the risk of cross contamination and infection, especially given the facility's population at risk for infection. Review of the facility's hand hygiene policy indicated that all personnel are to follow hand hygiene procedures, including before and after handling food or assisting residents with meals. The failure to adhere to these procedures was observed and acknowledged by staff, placing residents at risk for the development and transmission of communicable diseases and infections.