Infection Control Lapses During Meal Service and Failure to Use PPE for Enhanced Barrier Precautions
Penalty
Summary
Facility staff failed to follow proper infection prevention and control practices during meal service on two units. Observations revealed that certified nursing assistants wore the same gloves throughout the meal service, touching multiple surfaces and distributing food and beverages without changing gloves or performing hand hygiene. Additionally, a staff member placed clean table linens on the floor before placing them on dining tables, resulting in the linens coming into contact with the floor and then being used on tables. The soap dispenser in the dining room was not functioning, and hand sanitizer was not available in the area, further impeding proper hand hygiene. Interviews with staff confirmed awareness that gloves should be changed between tasks and that hand hygiene should be performed, but these practices were not followed. Staff also acknowledged that placing clean linens on the floor could cause cross-contamination. Facility policy documents reviewed stated that gloves should be changed between tasks, hand hygiene should be performed after glove removal, and linens should be handled in a way that prevents contamination. In a separate incident, a staff member from the therapy department failed to wear the required personal protective equipment (PPE) while providing direct care to a resident on enhanced barrier precautions. The staff member provided passive range of motion exercises wearing only gloves, despite signage and a bin of PPE outside the resident's room indicating that both gown and gloves were required. The staff member was unaware of the need for enhanced barrier precautions for this resident, who had physician orders for such precautions due to enteral feeding and wounds. Facility policy required the use of gown and gloves for high-contact care activities under enhanced barrier precautions.