F0880

E

Failure to Perform Hand Hygiene During Meal Service and Tray Passing

Fredericksburg, Texas Survey Completed on 01-08-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain an effective infection prevention and control program, specifically related to hand hygiene during meal service. An Activity Director assisted multiple residents with meals and meal tray delivery without performing hand hygiene between resident contacts, contrary to the facility’s handwashing/hand hygiene policy. The policy, dated 1/2025, states that hand hygiene is the primary means to prevent the spread of healthcare-associated infections and requires hand hygiene immediately before touching a resident, after touching a resident, and after touching the resident’s environment or contaminated surfaces.

Record review showed that one resident was an older female with moderate dementia with mood disturbance, type 2 diabetes mellitus with diabetic neurological complications, and generalized muscle weakness. Her MDS indicated moderate cognitive impairment and a need for set-up/clean-up assistance with eating, and her care plan documented that she could eat with tray set-up and supervision. Another resident was an older male with acute kidney failure, type 2 diabetes mellitus without complications, and blindness in one eye, with intact cognition and independence in eating, requiring only set-up assistance. A third resident was an older male with speech and language deficits following cerebrovascular disease, type 2 diabetes mellitus without complications, and joint pain, cognitively intact and independent with eating, with a care plan indicating he could eat with tray set-up and supervision.

On the observed date at midday, the Activity Director was seen in the dining area holding a spoon and offering bites of food to an unidentified female resident, then repositioning the resident’s wheelchair and handing her the spoon, without performing hand hygiene afterward. She then went to the open kitchen door, spoke with staff, took a hallway meal cart, and began passing trays. She delivered and set up lunch trays in the rooms of the three identified residents, moving items on bedside tables and discarding an item in the trash, but did not wash or sanitize her hands between residents or while in or exiting their rooms. During interview, the Activity Director stated she did not perform hand hygiene because she did not directly touch the food and believed it was more important to deliver trays quickly so food would not get cold. She reported having received hand hygiene training but could not recall specifics and stated she did not know she was supposed to use hand hygiene between residents, after feeding, or when passing trays. The Infection Preventionist and an RN both stated that staff should use hand hygiene before and after resident contact, including contact with resident belongings and the environment, and between each tray. Training records showed the Activity Director had completed hand hygiene and infection control training in November 2025, while the Infection Preventionist later stated staff had been trained on basic infection control and influenza but not hand hygiene, and that there was no current DON at the facility.