Failure to Provide Timely Oral and Incontinent Care
Penalty
Summary
The facility failed to provide necessary treatment and care services in accordance with professional standards of practice, comprehensive assessment, and care plan for three residents. Two residents, both dependent on staff for oral hygiene due to conditions such as traumatic brain injury, ventilator dependence, and gastrostomy status, did not receive proper oral care. Observations revealed one resident with dried, tan-colored matter on the lips and brown, dry matter at the corners of the mouth, as well as sticky, creamy matter inside the mouth. The other resident was observed with a dry, coated upper lip and a thick, peeling layer of skin. Staff interviews confirmed that oral care was not performed as required every shift, and facility policy stated that oral care should be provided every shift and as needed for residents with special needs. Another resident, who was comatose, dependent for toileting hygiene, and used an external urinary condom catheter, did not receive timely incontinent care. A family member reported finding the resident lying on a draw sheet saturated with dry urine up to the shoulders and upper body, and that nursing staff had not repositioned or changed the soiled linen. Facility records indicated a gap in required two-hour safety checks, with the resident not being checked for over six hours during the night. Staff interviews provided conflicting accounts regarding the resident's condition and care provided during the relevant period. Facility policies required residents who are unable to carry out activities of daily living independently to receive necessary services to maintain good nutrition, grooming, and personal and oral hygiene, as well as to be repositioned at least every two hours. The failure to adhere to these policies resulted in residents not receiving the necessary oral and incontinent care as outlined in their care plans and facility procedures.