Failure to Ensure Consistent Oral Hygiene Assistance
Penalty
Summary
A deficiency was identified when a resident with neurological conditions, respiratory failure, and seizure disorder was observed to have white buildup on his teeth, indicating inadequate oral hygiene. The resident reported brushing his own teeth but had not seen a dentist either in or out of the facility. Review of the resident's medical record showed he required setup or cleanup assistance with oral hygiene, and the care plan directed staff to assist with activities of daily living (ADLs) as needed, encouraging independence and providing adaptive equipment if necessary. However, CNA documentation indicated that oral care assistance was only provided 8 times in the last 14 days, and there were no nursing notes documenting concerns with the resident's oral health during the review period. Interviews with staff revealed that reminders to brush teeth were given, but there was no consistent follow-up or communication between shifts to ensure the resident completed oral hygiene. The CNA stated that the resident often postponed brushing his teeth and that it was not routinely communicated between shifts whether he had completed this task. The DON was unaware of where oral hygiene was documented and did not know if reminders were passed along during shift changes. These actions and inactions led to the resident not receiving appropriate treatment and services to maintain or improve his ability to carry out ADLs, specifically oral hygiene.