Failure to Follow Up on Provider Recommendations for Xerostomia
Penalty
Summary
A deficiency occurred when the facility failed to ensure that provider recommendations were followed up on in a timely manner for a resident with significant medical needs. The resident, who was cognitively intact and had diagnoses including heart failure and a hip fracture, required maximum assistance with mobility and toileting. The resident's care assessments identified contractures and limited range of motion that could impact nutritional status. Progress notes documented that the resident experienced a very dry mouth, which was noted as potentially contributing to dental decay and discomfort. Recommendations were made to assist with oral care and to have the medical doctor address the resident's xerostomia (dry mouth). Despite these recommendations, there was no documentation that the resident received any medication for xerostomia, and interviews with the resident, family members, and staff confirmed that no action had been taken to address the dentist's recommendation. The registered nurse acknowledged that the provider had not been contacted regarding the recommendation, and the director of nursing was unaware of the dentist's input. The facility did not have a specific policy for notifying providers of such recommendations, contributing to the lack of follow-up.