Failure to Develop Care Plan for Oral Health Needs
Penalty
Summary
A deficiency was identified when the facility failed to develop and implement a care plan addressing the oral health needs of a resident with natural teeth who required assistance with oral hygiene. The resident, admitted with diagnoses including anemia, major depression, anxiety, and abnormal gait and mobility, was documented in multiple dental exams as having moderate plaque buildup, inflamed and bleeding gums, and extremely inflamed gingivae. Dental professionals instructed staff to perform oral hygiene twice daily and recommended the use of Peridex mouthwash, yet the resident's care plan only addressed denture care and not the care of natural teeth. The unit manager confirmed that the resident did not have dentures, indicating the care plan did not reflect the resident's actual oral health needs.