Failure to Perform Hand Hygiene and Change Gloves During Meal Service
Penalty
Summary
Staff in both the first and second floor dining rooms failed to perform proper hand hygiene and change gloves as required during meal service. On multiple occasions, a speech therapist and nursing assistants were observed touching residents, wheelchairs, tables, and personal items, then handling food, drinks, and utensils without changing gloves or performing hand hygiene in between tasks. For example, a staff member was seen touching residents and their wheelchairs, then serving food and condiments, opening drink containers, and adjusting napkins, all while wearing the same gloves. Another staff member touched a resident's arm, a sink faucet, and a refrigerator, then handled a cup by the rim and gave it to a resident without washing hands. Similar lapses were observed with other staff, who handled drinks, straws, and cups by the areas that would come into contact with residents' mouths, again without appropriate glove changes or hand hygiene. These actions were confirmed through staff interviews, where staff acknowledged the need for hand hygiene and glove changes between resident contacts and after touching potentially contaminated surfaces. The failure to follow proper infection control protocols was observed in both dining rooms and involved multiple staff members during meal service, placing residents at risk for foodborne illnesses. The observations were corroborated by the facility's infection preventionist, who stated that gloves should be removed and hands washed when moving between residents and personal surfaces.