Failure to Provide and Document Oral Care for Dependent Resident
Penalty
Summary
The facility failed to provide oral care for a resident with moderate cognitive impairment and total dependence on staff for activities of daily living, including personal hygiene. According to the resident's care plan, staff assistance was required for oral care, shaving, and grooming. A review of the clinical record and Point of Care documentation over a 30-day period showed no evidence that oral care was provided to the resident during that time. Additionally, when the resident was admitted to the hospital, he was found to have crusty skin at the corners of his mouth and a yellow film buildup in his mouth and on his teeth. During an observation, staff were unable to locate the resident's toothbrush in the bathroom and only found one in a dresser drawer after searching. Staff interviews revealed uncertainty about the location of the resident's oral care supplies. The DON stated that staff were expected to set up the toothbrush and encourage the resident to brush his own teeth, with documentation required in the electronic medical record. Facility policy also required documentation of oral care in the electronic record.