Failure to Perform Hand Hygiene While Feeding Multiple Residents
Penalty
Summary
The facility failed to maintain an infection prevention and control program when a CNA did not perform hand hygiene while feeding two residents during the same meal service. During a lunch observation on 3/10/2026, CNA A sat between Resident #1 and Resident #2 and used the same right hand to alternately feed both residents without performing hand hygiene between residents. CNA A later acknowledged that residents should be assisted one at a time and that feeding two residents simultaneously without hand hygiene created a possibility of cross contamination. The facility’s own staff education practices included monthly in-services on infection control and weekly reminders on hand hygiene. Resident #1 was an older male with Alzheimer’s disease, dysphagia, and lack of coordination, admitted on 8/06/2025. His MDS assessment showed he required substantial/maximal assistance with eating, and his care plan indicated an ADL self-care performance deficit related to dementia and impaired balance, with an intervention stating he required setup to eat. Resident #2, admitted on 12/10/2024, had diagnoses including cerebral ischemia, muscle weakness, and lack of coordination, and also required substantial/maximal assistance with eating per his MDS, with a care plan noting an ADL self-care performance deficit related to confusion and dementia and an intervention that he required setup to eat. During the meal, LVN B was assigned to oversee lunch, ensure correct diets, and monitor resident safety, but did not notice the CNA’s feeding practice because she was de-escalating another resident situation. The DON stated that CNAs were expected to feed one resident at a time and perform hand hygiene between residents, and that a nurse was assigned to the dining room to monitor infection control practices, but these expectations were not followed during the observed incident.
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