Failure to Provide Oral Care and Lip Hydration for Dependent Resident
Penalty
Summary
Staff failed to provide required oral care and lip hydration for a resident who was unable to perform activities of daily living independently following a stroke. The facility's policy mandated oral care at least twice daily and the application of lip balm, especially for residents receiving nutrition through a feeding tube. Observations revealed the resident had dry, cracked, and peeling lips, with skin to the point of bleeding. Multiple staff members, including a CNA and LPN, were aware of the resident's condition but did not consistently provide or document oral care or lip moisturizer. The resident's care plan did not include tasks for oral hygiene or lip hydration, and staff interviews confirmed that these interventions were not routinely performed. The resident, who was moderately cognitively impaired and had significant physical limitations due to a recent stroke, was observed with ongoing oral health issues over multiple days. Staff acknowledged the problem but failed to initiate or document appropriate care measures. The administrator confirmed that the aide task for oral care was not set up and recognized the importance of such care, particularly for residents with feeding tubes. The deficiency was identified through observation, staff interviews, and record review, which showed a lack of adherence to facility policy and insufficient care planning for the resident's oral health needs.