Failure to Follow Hand Hygiene Protocol During Meal Service
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, specifically regarding hand hygiene practices during meal tray distribution. Observations revealed that a CNA did not sanitize or wash her hands between passing lunch trays to three residents. This lapse occurred despite the facility's policy requiring staff to wash hands before starting to pass trays, sanitize between trays, and wash hands again after every third tray. The CNA acknowledged being trained on the policy but admitted to forgetting to perform hand hygiene due to nervousness. The three residents involved had significant medical histories, including conditions such as polyneuropathy, hypertension, cognitive communication deficits, dysphagia, kidney disease, heart failure, chronic pain, dementia, diabetes, and osteoporosis. Their cognitive statuses ranged from intact to severe impairment, as indicated by their BIMS scores. The failure to follow proper hand hygiene protocols occurred during the lunch meal service, directly impacting these residents. Interviews with facility staff, including the CNA, Infection Preventionist, Administrator, and DON, confirmed awareness of the hand hygiene policy and the importance of preventing cross-contamination. Staff described the monitoring process as involving observation and management walkarounds. Despite this, the required hand hygiene steps were not followed during the observed meal service, resulting in a deficiency in the facility's infection control practices.