Failure to Follow Hand Hygiene, Enhanced Barrier Precautions, and Meal Tray Handling Practices
Penalty
Summary
The deficiency involves the facility’s failure to follow its Infection Prevention and Control Program – Hand Hygiene Policy and enhanced barrier precaution practices, as well as improper handling of meal trays. The hand hygiene policy required handwashing with soap and water before eating and after using the restroom, when hands are visibly soiled, and after contact with residents with infectious diarrhea. Surveyors observed an LPN serving meal trays to two residents in their rooms without offering or encouraging hand hygiene before eating. During a wound vac dressing change for another resident, the same LPN washed her hands and donned a gown and gloves, removed the resident’s socks, Ace bandage, Kerlix, and old dressing, then removed and reapplied gloves multiple times without washing her hands between glove changes after cleaning the wound. The LPN later stated she should have washed her hands between glove changes and thought she had. Surveyors also observed failures to follow enhanced barrier precautions and proper food cart practices. Enhanced Barrier Precaution signage was posted on a resident’s door, but two CNAs entered the room and transferred the resident from wheelchair to bed without donning the required PPE; one CNA later acknowledged PPE should have been used before the transfer. In a separate observation, an RN identified that there was one undelivered tray remaining in the food cart, then removed a dirty food cover and meal tray from the same cart containing undelivered meals. The RN later stated that the dirty food cover and meal tray should not have been placed in the meal cart when undelivered lunch trays were still inside.
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