Failure to Provide Adequate Oral Hygiene to Dependent Resident
Penalty
Summary
A dependent resident with severe cognitive impairment, functional limitations, and a need for substantial assistance with activities of daily living, including oral hygiene, was not provided adequate oral care. The resident's care plan specified the need for daily oral hygiene assistance and monitoring for signs of dehydration and dental problems. Despite documentation indicating that oral care was being provided almost daily, multiple assessments and family concerns indicated otherwise. The resident's dental records showed a significant decline in oral health over several months. While earlier dental visits did not note any major concerns, a later assessment by the facility dentist identified multiple decayed teeth, heavy plaque, and poor oral hygiene, recommending increased staff assistance with daily oral care. An outside dental examination further confirmed extremely heavy plaque buildup, gingivitis, and pain, attributing these issues to inadequate home care. The resident's family also raised concerns about mouthwash not being used and reported that the dentist described the oral condition as a result of neglect. Interviews with staff and administration revealed that oral hygiene was not being performed as frequently as required, and there were ongoing concerns from families about the adequacy of oral care. Staff confirmed that oral hygiene was sometimes neglected, and the administrator was unable to explain the deterioration in the resident's oral health despite documentation of care. The deficiency was substantiated by direct observations, medical record reviews, and interviews, all indicating a failure to provide necessary assistance with oral hygiene to a dependent resident.