Failure to Provide Necessary Oral Care for Resident
Penalty
Summary
The facility failed to ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene. Specifically, the resident, who was cognitively intact and required substantial assistance with oral hygiene, did not receive oral care as planned. The facility's policy required that residents who could not independently perform activities of daily living receive necessary services to maintain oral hygiene. However, observations and interviews revealed that the resident had not received oral care on multiple occasions, resulting in a dry mouth and thick white substance on their mouth and tongue. Interviews with staff, including a Certified Nurse Aide and Licensed Practical Nurse Unit Manager, confirmed that oral care was not provided as required. The Certified Nurse Aide admitted to missing oral care in error, while the Licensed Practical Nurse Unit Manager was unaware of the deficiency. The resident's care plan indicated the need for substantial assistance with oral hygiene, and the facility's policy emphasized the importance of maintaining oral hygiene to prevent infection and ensure comfort. Despite these guidelines, oral care was not documented as being performed on several days, highlighting a lapse in the facility's adherence to its own policies.
Plan Of Correction
Plan of Correction: Approved March 6, 2025 The following corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: - Educate #8 C.N.A and all C.N.A’s on oral care under ADL’s - Resident #119 was provided oral care The facility will identify other residents having the potential to be affected by the same deficient practice and the following corrective action will be taken: - Audit ADL/Oral care for residents who are care planned for assistance The following measures will be put in place and/or systemic changes will be made to ensure that the deficient practice does not recur: - Education on ADL/Oral Care to all CNA’s - Check Resident #119 morning and afternoon for 2 weeks, then weekly x3 months for ensuring oral care is being provided. The corrective action(s) will be monitored to ensure the deficient practice will not recur: - Audit Oral/ADL care for residents who need assistance x5 per unit/week for 3 months until 100% The date for correction and the title of the person responsible for correction of each deficiency: - Date of Correction: 3/5/2025 - Person Responsible: Nurse Manager