Failure to Provide Necessary Oral Care Due to Staff Role Confusion and Missed Documentation
Penalty
Summary
A deficiency was identified when a resident did not receive necessary oral care as required. The issue was first brought to attention by the resident's family member, who expressed concern about the resident's oral hygiene. Upon observation, the surveyor noted that the resident's tongue appeared yellow, dry, and crusty, and the front upper teeth had a thick, creamy film. This condition was confirmed during a joint observation with the unit manager, who stated that the respiratory therapist was responsible for oral care, performed one or two times per shift as recommended by respiratory therapy. Further interviews revealed confusion among staff regarding responsibility for oral care. Respiratory therapists reported that their duties were limited to suctioning and that nurses were responsible for oral care. A nurse confirmed that nurses were responsible for oral care and that it should be documented on the MAR/TAR, with an active medical order for oral care every shift. However, review of the treatment administration records showed missing documentation for oral care on several shifts, indicating that the required care was not consistently provided.