Failure to Provide Necessary Oral and Personal Hygiene for Dependent Resident
Penalty
Summary
Facility staff failed to provide necessary assistance with activities of daily living (ADLs), specifically personal and oral hygiene, to a resident who was completely dependent on staff for self-care. The resident, who had diagnoses including hemiplegia following a stroke, cognitive communication deficit, and vascular dementia, was nonverbal, unable to make decisions, and received nutrition via a G-tube. Observations revealed the resident had dry, chapped, and cracked lips with flaking, indicating a lack of adequate oral care. Staff interviews confirmed that mouth care was typically provided after meals, but since the resident did not eat orally, this care was not consistently given. Further interviews with facility staff, including a CNA, the Infection Prevention Nurse, and the DON, confirmed that both facility and hospice staff were responsible for providing personal and oral care, regardless of the resident's hospice status. Facility policies required staff to assist residents unable to perform ADLs independently and to maintain personal and oral hygiene. However, the observed condition of the resident's lips and staff statements indicated that these policies were not followed, resulting in the resident not receiving the necessary care to maintain oral hygiene and comfort.