Failure to Perform Hand Hygiene Between Handling Soiled and Clean Dishes in Dish Room
Penalty
Summary
Surveyors identified a deficiency in kitchen infection control practices when a dietary aide working in the dish room failed to perform required hand hygiene between handling soiled and clean dishes. One dietary aide was observed scraping and dumping trays, placing utensils, plates, and cups into sanitizer, and explained that with two people present, one would run dishes through the dishwasher while the second person would handle the clean dishes. A second dietary aide then entered the dish room and was observed repeatedly pushing racks of dirty dishes into the dishwasher and then removing clean trays and dishes without changing gloves or performing hand hygiene, despite a handwashing station being present in the dish room. The same dietary aide continued to alternate between handling dirty dish racks and removing clean domes, trays, and dishes from the dishwasher, changing gloves multiple times but never washing hands between tasks. Another dietary aide reported by telephone that dishwashing was supposed to be done by three staff, but they often only had two, and described scraping, loading the dishwasher, and pulling carts with an emphasis on changing gloves as much as possible. The dietary manager stated that the facility’s process required two people in the dish room, with one scraping and setting up dishes and the other pushing dishes through the dishwasher and pulling them out, and confirmed that hand hygiene should be performed after pushing dishes through, followed by glove changes before handling clean dishes to prevent cross contamination. Facility policies and training documents on cleaning, sanitizing, ware washing, and handwashing required staff to wash hands prior to donning gloves and between glove changes, including after touching waste or contaminated surfaces and after leaving the dish area. This failure had the potential to affect 127 residents who received meals from the kitchen, out of a census of 131 residents, with four residents NPO.
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