Failure to Perform Hand Hygiene During Meal Tray Distribution
Penalty
Summary
Facility staff failed to perform appropriate hand hygiene during the distribution and setup of meal trays for nine residents in one of three observed dining areas. According to the facility's own hand hygiene policy, staff are required to use proper hand hygiene during mealtimes, specifically when passing trays. Observations on a specified date revealed that a Certified Nursing Assistant (CNA) delivered and set up lunch trays for multiple residents without performing hand hygiene between each interaction. The residents involved had a range of medical conditions, including heart failure, dementia, chronic kidney disease, Parkinson's disease, diabetes, and other chronic illnesses. Their care plans indicated varying levels of cognitive impairment and physical dependency, with most requiring assistance or supervision with eating and personal hygiene. Despite these needs, the CNA did not follow hand hygiene protocols while assisting with meal setup, as confirmed by both direct observation and staff interviews. Interviews with the CNA and the Director of Nursing (DON) confirmed that hand hygiene was not performed as required during the meal service. The DON acknowledged that infection prevention and control practices were not maintained during the observed lunch service, specifically noting the failure to perform hand hygiene between serving each meal tray.