Failure to Provide Oral Hygiene for Dependent Resident
Penalty
Summary
A resident who was dependent for all activities of daily living, non-verbal, and receiving nutrition via PEG tube with a diagnosis of developmental disorder of speech and language, stroke, and dysphagia, was observed multiple times with thick, dried mucus over their teeth, cracked and scabbed lips, and dry skin on the lips. The resident's mouth condition remained unchanged over several observations, and there was no evidence in the electronic medical record that oral care had been refused in the past 30 days. The resident was unable to communicate effectively but indicated through limited response that mouth care had not been provided. Interviews with staff, including an LPN and the DON, confirmed that the resident was dependent for personal hygiene and that oral care should be provided as needed and on a schedule. The LPN could not confirm if mouth care had been performed, and the facility's policy required checking residents throughout the shift for care and hygiene needs, as well as reporting any prolonged absence of ADL care. Despite these requirements, the resident was found in need of mouth care, and there was no documentation of refusal or provision of such care.