Failure to Treat Oral Candidiasis in Dependent Resident
Penalty
Summary
The facility failed to provide necessary treatment for a resident diagnosed with candidiasis, resulting in the resident having an untreated oral fungal infection since 3/29/2025. The resident, who was dependent on nursing staff for all activities of daily living including oral hygiene, was observed to have a dry mouth and a white tongue. Despite the resident's documented diagnosis of candidiasis and complete dependence on staff for care, there was no order in the resident's chart for treatment of the infection. Nursing staff and supervisors acknowledged the presence of candidiasis and the lack of a treatment order, with the Director of Nursing confirming that licensed staff should have contacted the physician for appropriate medication. Interviews with staff revealed that while nursing staff were responsible for oral care and respiratory therapists for oral suction, there was a lack of communication and follow-through regarding the resident's condition. The respiratory therapist supervisor noticed signs of oral thrush but did not report it, and the nursing staff did not initiate treatment or notify the physician. Facility policy required provision of care and services to maintain personal and oral hygiene for residents unable to perform these tasks independently, but this was not followed in the case of this resident.