Failure to Provide Consistent Oral Care Assistance
Penalty
Summary
A deficiency was identified when a resident, who was assessed as having intact cognition but was dependent on staff for oral care and eating due to medical conditions including hypertension, stroke, hemiplegia, anxiety, and depression, did not consistently receive oral hygiene assistance as required. The resident's care plan specified maximum assistance with oral hygiene, but documentation for multiple days in February and March showed no record of oral care being provided. Interviews with the resident confirmed that oral care was inconsistently performed, depending on which staff were on duty, and the family expected oral care after every meal. The DON confirmed that the facility's expectation was for oral care to be provided twice daily, but acknowledged that this was not consistently done according to the documentation reviewed. Observation further revealed that the resident had missing teeth and experienced gum bleeding during oral care, although no pain was reported. The facility's policy required that residents unable to perform activities of daily living independently receive necessary assistance, including oral hygiene, in accordance with their care plan and assessed needs. The lack of consistent oral care and incomplete documentation indicated a failure to provide the required assistance for activities of daily living for this resident.