Failure to Provide Routine Oral Hygiene for Dependent Resident
Penalty
Summary
The facility failed to ensure that routine oral hygiene was provided for a resident who was dependent on staff for activities of daily living. The resident had moderately impaired cognition, required substantial assistance with oral care, and had a care plan indicating the need for extensive staff assistance due to having full upper dentures and natural lower teeth with some missing. Review of documentation showed no record of oral care being provided over a one-month period. The resident reported that staff were supposed to help with brushing teeth twice daily but had not been doing so, and that previously staff would leave a basin and toothbrush but no longer did even that. A nursing assistant assigned to the resident stated she did not provide oral care because she believed the resident had no real teeth, despite the resident having remaining lower teeth. Observation confirmed the resident had yellowed lower teeth with visible white/yellow matter around the edges. The unit nurse manager confirmed that oral hygiene was the standard of care and should be performed preferably twice daily, and that documentation should be present in the point of care charting, which was not found. A policy on oral care was requested but not provided.