Failure to Provide Required Oral Care During Morning ADL Assistance
Penalty
Summary
A deficiency occurred when a resident who required assistance with activities of daily living (ADLs), specifically personal hygiene and oral care, did not receive mouth care as required by her care plan. The resident, an elderly female with diagnoses including Alzheimer's disease, muscle weakness, lack of coordination, hypertension, constipation, hyperlipidemia, anemia, and dementia, was assessed as needing supervision or touching assistance with personal hygiene. On the morning in question, observation revealed the resident was clean and dressed, but during an interview, she reported that her teeth had not been brushed that morning, although her hair had been brushed. Further investigation through interviews with the CNA and LVN confirmed that oral care was not provided during the initial morning care routine. The CNA stated she had not brushed the resident's teeth and was unsure if the hospice aide had done so. The facility's policy and the resident's care plan both required assistance with oral hygiene, but this was not carried out as expected. The DON confirmed that staff were responsible for providing ADL care, including oral care, and that training was provided regularly.