Failure to Develop and Implement Comprehensive Oral Hygiene Care Plan
Penalty
Summary
A deficiency was identified when a resident with neurological conditions, respiratory failure, and seizure disorder did not have a comprehensive, person-centered care plan addressing oral hygiene needs. The resident was observed with white buildup on his teeth and reported brushing his own teeth, but had not seen a dentist during his stay. The Minimum Data Set (MDS) assessment indicated the resident required setup or cleanup assistance with oral hygiene, yet the care plan only generally addressed assistance with activities of daily living (ADLs) and did not specifically include measurable objectives or timeframes for oral hygiene care. Certified Nursing Assistant (CNA) documentation showed the resident received oral care assistance only 8 times in 14 days, and there were no documented concerns about teeth or gums in the nursing progress notes. Interviews with staff revealed that reminders and encouragement were provided, but there was no consistent communication between shifts regarding whether the resident completed oral hygiene. The Director of Nursing confirmed that a care plan should have been developed to address the resident's need for more assistance with oral hygiene.