Failure to Provide Adequate Oral Hygiene for Memory Care Residents
Penalty
Summary
The facility failed to ensure that residents on the secured memory care unit who were dependent on staff for dental care received appropriate oral hygiene services. Observations, interviews, and record reviews revealed that 7 out of 9 residents reviewed for ADL assistance did not consistently receive oral care. Specific findings included residents with visible dental issues such as broken or discolored teeth, plaque buildup, and missing oral care supplies in their rooms. Dental records indicated poor oral hygiene, red and inflamed tissues, heavy plaque, and gross decay in several residents. Despite documentation that oral care was part of daily routines and staff competency checklists included oral hygiene, actual care practices did not align with these standards. Staff interviews confirmed that residents were dependent on staff for daily hygiene, and supplies were reportedly accessible, yet oral care items were often missing or improperly stored in resident rooms. Nursing and dental progress notes documented ongoing dental issues and poor oral hygiene among residents with dementia and other cognitive impairments. The deficiency was further substantiated by an anonymous concern that staff were not brushing residents' teeth, and by direct observations of inadequate oral care supplies and poor oral health conditions among multiple residents.