Failure to Perform Hand Hygiene During Meal Service
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by a medication aide's failure to perform proper hand hygiene while serving meals in the main dining room. Observations revealed that the aide, after washing her hands and adjusting her clothing, did not use hand sanitizer before serving lunch trays to multiple residents. The aide had direct contact with residents, including touching their hands and shoulders, and handled meal trays and utensils without performing hand hygiene between each interaction. Hand sanitizer was available in the dining room, but was not used by the aide during the meal service. Record reviews indicated that the residents involved had significant medical conditions, including heart failure, hypertension, diabetes, atrial fibrillation, and cognitive impairments, requiring varying levels of assistance with activities of daily living. Interviews with the aide confirmed she did not complete hand hygiene after resident contact, despite being educated on the procedure. The Director of Nursing acknowledged that staff are required to perform hand hygiene after resident contact and that supplies were available, but also stated that no in-services on hand hygiene had been conducted since her recent arrival at the facility. Facility policies required regular staff education and adherence to hand hygiene protocols to prevent the spread of infections.