Failure to Provide Oral Care Assistance
Penalty
Summary
The facility failed to ensure proper oral care for a resident, identified as R81, who was admitted with diagnoses including atherosclerotic heart disease and essential tremor. R81 was cognitively intact, as indicated by a score of 14 out of 15 on the Brief Interview for Mental Status, and required setup or clean-up assistance for oral hygiene due to impairments in one upper and one lower extremity. Despite these needs, R81 reported that their teeth had not been brushed since admission, and they had not been provided with the necessary supplies to perform oral hygiene independently. Observations confirmed that R81's toothbrush was still in a sealed package, and no toothpaste was available in their room. Further investigation revealed that the facility's staff, including CNA N, did not offer the necessary setup assistance for oral care, as R81 was not feeling well on the morning of the observation. Documentation in R81's medical record indicated an order for the nurse to prepare a toothbrush for oral care after medication pass in the morning and at bedtime, which was marked as completed in the Medication Administration Record. However, R81 only received assistance to brush their teeth after the State Agency's involvement, highlighting a lapse in the facility's adherence to the prescribed oral care routine. The Director of Nursing confirmed that residents should receive oral care at least once a day, but R81's experience demonstrated a failure to meet this standard until external intervention occurred.