Failure to Adhere to Hand Hygiene Protocols During Meal Service
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple staff members not adhering to hand hygiene protocols during meal tray distribution. Observations revealed that a CNA did not sanitize her hands after delivering meal trays to several residents, nor after touching her own clothing, and continued to handle food and resident items without performing hand hygiene. Another CNA was observed failing to perform hand hygiene between resident rooms while passing lunch trays, despite having received training on infection control and acknowledging the importance of hand hygiene to prevent cross-contamination. Additionally, the Dietary Manager (DM) was observed distributing meal trays, hugging, fist bumping, and shaking hands with residents without conducting hand hygiene between these interactions. Interviews with the DM and other staff confirmed that infection control training had been provided, and that facility policy required hand hygiene before and after resident contact, as well as between each resident when passing meal trays. Despite this, the DM did not follow these protocols during the observed meal service. Interviews with the Director of Nursing (DON), Assistant Director of Nursing (ADON), and Administrator confirmed that all staff were expected to follow hand hygiene protocols, and that monitoring and training were in place. Facility policies reviewed indicated clear expectations for hand hygiene before and after resident contact, after touching resident environments, and when handling food. However, the lack of adherence to these protocols by multiple staff members during meal service constituted a failure to implement the infection prevention and control program as required.