Failure to Provide Consistent Oral Care for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident with dementia, congestive heart failure, and ischemic cardiomyopathy did not consistently receive oral care as required. The resident had recently experienced a decline in health, affecting cognition and dexterity, which increased reliance on staff for activities of daily living, including oral hygiene. During an interview and observation, the resident's representative expressed concern about the lack of regular oral care, and notable bad breath was observed. Record review showed that oral hygiene was ordered to be performed every shift (twice daily), but documentation revealed that the resident only received oral care once daily on ten occasions out of 56 opportunities. Additionally, the resident's Kardex did not include instructions for oral hygiene assistance, and the care plan lacked interventions addressing oral hygiene needs. The DON confirmed that oral care should be performed at least once per 12-hour shift and acknowledged the care plan should have been updated to reflect the resident's current needs.