Failure to Provide Assistance with Personal Hygiene and Oral Care
Penalty
Summary
The facility failed to provide necessary assistance with personal hygiene, specifically oral care and shaving, as directed by the care plans for two residents. One resident, with diagnoses including chronic kidney disease and high blood pressure, required assistance with most activities of daily living (ADLs) and was care planned for set-up and clean-up assistance with oral care. However, the care plan and Kardex did not specifically address oral care, and documentation showed that out of 60 opportunities in the past 30 days, oral care was only documented once as refused. Observations confirmed that staff did not offer or provide oral care during morning routines, and the resident reported never being asked or assisted with brushing teeth. Another resident, with chronic kidney disease, depression, morbid obesity, and diabetes, required setup assistance for personal hygiene, including shaving. Despite expressing a preference for having chin hair shaved and being unable to stand at the mirror, the resident was observed with long chin hair over multiple days. The resident stated that staff were often too busy to assist, and staff interviews revealed that the resident did not have a razor and that this need had not been communicated to nursing staff. The DON was unaware of the resident's unmet need for shaving assistance. The facility's policy on activities of daily living required that residents unable to perform ADLs receive necessary services to maintain grooming and personal hygiene, including oral care and shaving. Despite this policy, both residents did not receive the required assistance, as evidenced by lack of documentation, staff interviews, and direct observations.