Failure to Provide Oral Hygiene for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident with multiple sclerosis and non-Alzheimer's dementia, who was dependent on staff for activities of daily living (ADLs), was not provided with adequate oral hygiene. The resident was admitted with substantial or maximal assistance needs for eating and was dependent for toileting and bed mobility, requiring the use of a Hoyer lift. The care plan indicated a risk for poor oral hygiene and directed staff to provide mouth care as part of personal hygiene. However, observations and interviews revealed that staff did not brush the resident's teeth after meals, despite this being the expected practice. The resident's family member reported concerns about oral care, noting that the resident previously brushed her teeth after every meal at home, and an observation confirmed a yellow film on the resident's teeth. Further review of the medical record showed no documentation that oral care was provided after breakfast or lunch on the observed date. Staff interviews confirmed that both a registered nurse and a certified nursing aide, who fed the resident, did not perform oral hygiene after meals. The facility's policy required that residents unable to perform ADLs independently receive necessary services to maintain personal and oral hygiene, but this was not followed for the resident in question.