Failure to Provide Consistent Oral Hygiene Assistance
Penalty
Summary
A deficiency was identified regarding the facility's failure to provide appropriate oral hygiene care to a resident with significant medical needs, including Parkinson's disease, dysphagia, and a need for palliative care. The resident required supervision or assistance with oral hygiene, as documented in the care plan and Minimum Data Set (MDS). Despite clear instructions posted on the resident's door and care plan interventions specifying the need for staff assistance with oral care, documentation and interviews revealed that oral hygiene was not consistently provided as required. CNA documentation showed that oral care was only performed sporadically over a one-month period, rather than the expected twice daily frequency. Interviews with staff confirmed that oral hygiene should be performed and documented twice daily, but this was not consistently done, and no clear reason was provided for the lapses. Further evidence of inadequate oral care was found in dental records, which noted heavy debris, gum inflammation, and tooth decay, necessitating dental intervention. The resident's family member also reported that oral hygiene was not performed regularly, resulting in dental issues. Staff interviews indicated that oral hygiene was a CNA responsibility and should be documented, with refusals reported to nursing staff. However, there was no documentation of refusals or consistent provision of care, and leadership was unable to explain the lack of compliance with the care plan and posted instructions.