Failure to Provide Oral Care and Timely Reporting for Dependent Resident
Penalty
Summary
The facility failed to provide oral care for a resident who was dependent on staff for all activities of daily living, including oral hygiene. The resident had a history of traumatic subdural hemorrhage, pneumonia, and epilepsy, and was assessed as having moderately impaired cognition and being fully dependent on staff for personal care. The resident's care plan specifically required staff to assist with personal hygiene and provide oral care. On the day in question, the resident was observed in bed with dry, cracked lips. A CNA assigned to the resident that day initially stated that oral care had been provided, but upon further questioning, admitted that oral care was not given. The CNA described the resident's tongue as unclean, with a thick white and yellow coating, and stated that this condition had persisted for a long time. The CNA also admitted to not reporting the condition to the nurse until prompted by the surveyor and did not provide oral care because the resident began to scream. Interviews with facility staff, including the LVN, Assistant Director of Nursing, and Director of Staff Development, confirmed that oral care was not provided as required and that the condition of the resident's tongue was not reported in a timely manner. Review of facility policies indicated that oral care should be provided at least once per shift and that staff are responsible for monitoring and assisting with activities of daily living, including mouth care, and reporting any changes in resident condition.