Failure to Provide and Document Required Oral Care
Penalty
Summary
The facility failed to ensure that a resident received oral care as required. The resident, who had diagnoses including muscle weakness, abnormalities of gait and mobility, and dementia with moderately impaired cognition, required supervision for oral hygiene and personal hygiene according to their Minimum Data Set (MDS) assessment. Facility records indicated that oral care was to be provided every shift and as needed. However, a review of the resident's Point of Care Response History showed that from 4/21/2025 to 5/19/2025, oral care was not provided every shift as required. During interviews, an LVN confirmed that staff were responsible for ensuring the resident performed or received oral care every shift. The DON stated that if oral care was not documented, it was considered not done, and emphasized that oral care should be provided at least every shift. The facility's policy on mouth care required documentation of the date, time, and staff member providing care. The lack of documented oral care placed the resident at risk for poor dental hygiene and increased risk for oral infections.