Failure to Provide Timely Oral Care and Suctioning for Ventilator-Dependent Resident
Penalty
Summary
Facility staff failed to provide necessary oral care and oral suctioning for a resident with a tracheostomy, ventilator dependence, and severe cognitive impairment. The resident was observed with dried secretions covering the entire mouth, despite physician orders for suctioning every two hours as needed and the use of Chlorhexidine Gluconate Solution for oral care every shift. The resident was completely dependent on staff for all activities of daily living, including oral hygiene, and lacked the capacity to make decisions or communicate needs. Interviews with facility staff, including a respiratory therapist, LVN, respiratory therapy supervisor, and RN, confirmed that oral care and suctioning were required to prevent infection and maintain the resident's dignity. Facility policy required daily oral care for all patients to maintain hygiene and prevent complications. Despite these requirements and staff awareness, oral care and suctioning were not performed in a timely manner, as evidenced by the presence of dried secretions during observation.