Failure to Develop Comprehensive Oral Care Plan for Resident with Hemiplegia
Penalty
Summary
The facility failed to develop a comprehensive care plan addressing oral care needs for a resident with a history of cerebrovascular accident (CVA) resulting in hemiplegia and moderate cognitive impairment. The resident was admitted with diagnoses including nontraumatic intracranial hemorrhage, hemiplegia and hemiparesis affecting the left side, and had a gastrostomy. Review of the resident's Activities of Daily Living (ADL) care plan showed a focus on self-care deficits related to hemiplegia, but no care plan was developed for oral care. Facility policy required a comprehensive care plan to be completed within seven days after the Minimum Data Set (MDS) was completed, but this was not done for oral care in this case. Observations revealed the resident had a dry, cracked, and peeling lower lip on two separate occasions. Interviews with staff confirmed that oral care was not performed, with a CNA stating the resident could wash her dentures herself. Both the RN and the administrator confirmed the absence of an oral care plan, and the MDS nurse acknowledged that staff could not be expected to provide care that was not included in the care plan. The lack of a care plan for oral care resulted in staff not being aware of or providing necessary oral hygiene for the resident.