Failure to Perform Hand Hygiene During Meal Assistance
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically related to hand hygiene during meal assistance. Surveyors observed a Speech Therapist feeding a resident with severe cognitive impairment and dysphagia who had a care plan addressing potential nutritional problems and the need for a calm, quiet setting at mealtimes. During this feeding, the Speech Therapist touched her hair twice and continued feeding without using hand sanitizer, contrary to the facility’s hand hygiene policy, which requires hand hygiene before and after assisting a resident with meals. Another resident with vascular dementia, dysphagia, and schizoaffective disorder was care planned as dependent on staff for eating and requiring substantial/maximal staff assistance. An LVN was observed feeding this resident, touched her own hair, and did not use hand sanitizer before continuing to feed the resident, despite having sanitizer gel available. The LVN later acknowledged she did not use hand sanitizer while feeding this resident and stated she was not aware she had touched her hair at the time. The same LVN then moved from assisting the second resident to assist a third resident, an elderly female with Alzheimer’s disease and a cognitive communication deficit who was care planned for potential nutritional problems and ordered a regular diet with thin liquids. The LVN did not sanitize her hands between residents or prior to returning to assist the second resident. The DON stated that staff were expected not to touch their hair while feeding residents and to sanitize their hands between assisting residents, and confirmed that these actions placed the involved residents at risk of infection. The facility’s hand hygiene policy, dated August 2024, identified hand hygiene as the primary means to prevent the spread of infections and required use of alcohol-based hand rub or soap and water before and after assisting a resident with meals.
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