Failure to Provide and Document Oral Care for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident with multiple complex medical conditions, including multiple sclerosis, neuropathy, seizures, and functional quadriplegia, was observed to have poor oral hygiene. The resident was found with food particles on the lips and white and orange material on the teeth. The resident was assessed as being severely cognitively impaired and fully dependent on staff for all activities of daily living, including oral care. Despite this, there was no documentation in the nursing progress notes of oral care being provided or refused over a period of several months. Interviews with staff revealed that the facility's protocol required documentation of both the provision and refusal of oral care, with CNAs expected to notify LVNs and the Director of Staff Development if a resident refused care. However, both the LVN and DON confirmed that there was no documentation of oral care or refusals for this resident, indicating that the required care was not provided. The facility's policies also specified that residents unable to perform activities of daily living should receive necessary services to maintain personal and oral hygiene, which was not met in this case.