Failure to Perform Hand Hygiene During Meal Tray Service
Penalty
Summary
The facility failed to maintain infection control practices during meal tray service, as observed with three residents. Certified nursing assistant (CNA) #100 was seen assisting residents with meal tray setup and other tasks, such as raising the head of the bed and removing linens, without performing hand hygiene before or after these activities. This occurred despite the presence of hand sanitizer on the meal delivery cart and the facility's policy requiring hand hygiene by all employees. CNA #100 confirmed during interviews that hand hygiene was not performed during the lunch tray pass. The residents involved had significant medical histories, including dementia, diabetes mellitus with chronic kidney disease, Crohn's disease, heart failure, arthritis, peripheral vascular disease, and cognitive impairment. Observations were made both in resident rooms and the dining area, affecting all three residents observed during the meal service. The failure to perform hand hygiene had the potential to impact all thirteen residents on the unit, with a total facility census of seventy-six.