Failure to Provide Oral Care for Dependent Residents
Penalty
Summary
Staff failed to provide necessary oral care for three residents who were dependent on staff for activities of daily living (ADLs). Each resident had significant medical conditions, including tracheostomy, gastrostomy, metabolic encephalopathy, quadriplegia, and other serious diagnoses, and their care plans specifically required staff assistance with daily oral care. Despite these documented needs, observations revealed that residents had visibly poor oral hygiene, such as dry lips with crusted secretions and yellow, residue-covered teeth. Interviews with staff confirmed that oral care had not been provided as required, and staff were unsure when the last oral care was performed. Family members of two residents also expressed concerns about the lack of oral care, noting persistent issues with dirty teeth and dry, crusted lips. The facility's policy required oral care to be offered before breakfast and at bedtime, and the Director of Nursing acknowledged that nursing assistants were responsible for providing this care. However, the observed conditions and staff interviews demonstrated that oral care was not consistently performed for residents who were unable to perform this task themselves.