Failure to Perform Hand Hygiene During Meal Tray Distribution
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) failed to perform proper hand hygiene while distributing meal trays to residents on Hall 500. During an observation, the CNA did not wash or sanitize her hands before entering or exiting resident rooms or between handling meal trays for multiple residents. The CNA entered several rooms, set up meal trays, opened utensils, repositioned a resident, and assisted with meal setup, all without performing hand hygiene between residents. These actions were directly observed and documented during the meal service. Interviews with facility leadership, including the Assistant Director of Nursing (ADON), Director of Nursing (DON), and the Administrator, confirmed that staff are expected to sanitize their hands between residents when passing trays, as outlined in the facility's hand hygiene policy. The policy specifies that hand hygiene should be performed before and after providing any type of care and after contact with potentially contaminated surfaces. The failure to follow these procedures was acknowledged by facility leadership during interviews.