Failure to Provide Required Oral Care for Dependent Resident
Penalty
Summary
The facility failed to provide necessary oral care for a resident who was dependent on staff for all activities of daily living and required tube feeding. The resident had multiple diagnoses, including hypothyroidism, anxiety, major depressive disorder, muscle weakness, Parkinson's disease, and hypoxia, and was documented as having severely impaired cognition and being rarely or never understood. The care plan specified that mouth care was to be provided at least daily due to oral/dental health problems, including inflamed gums, and that the resident was nothing by mouth (NPO) and received continuous tube feeding. During observation, the resident was found in bed with a thick yellow substance on her lips and in her mouth, indicating that mouth care had not been performed as required. Interviews with staff revealed a lack of clear documentation and accountability regarding the provision of mouth care for residents with internal feedings. The licensed nurse acknowledged that cleaning of the mouth for residents with internal feedings was not documented, although staff were aware it should be done at least every shift. Certified nurse aides and administrative nursing staff stated that it was the responsibility of all nursing staff to ensure residents remained clean, but there was no evidence that mouth care had been provided for this resident as directed by the care plan and facility policy.