Failure to Provide Oral Care for Dependent Resident with Tracheostomy
Penalty
Summary
Facility staff failed to provide oral care to a resident who was dependent and had a tracheostomy. The resident was admitted with a tracheostomy and required assistance with activities of daily living, including oral care. A review of the resident's care plan showed no interventions for tracheostomy or oral care. Interviews with the Director of Respiratory Therapy revealed that respiratory therapists were responsible for providing and documenting oral care for dependent residents, but documentation was inconsistent among staff. Further review of the facility's tracheostomy care policy indicated that it only addressed tracheostomy care and did not include oral care procedures. The lack of documentation and absence of oral care interventions in the care plan led to the deficiency, as the resident did not receive the required oral care during their stay.