NPO Resident Received Liquid by Mouth During Oral Care
Penalty
Summary
A deficiency occurred when a resident with a physician's order for Nothing by Mouth (NPO) received a small amount of liquid chlorhexidine solution orally during oral care. The resident, who was cognitively impaired and required total assistance with activities of daily living and oral hygiene, had a medical history including cerebral infarction, emphysema, acute and chronic respiratory failure with hypoxia, diabetes mellitus, atrial fibrillation, tracheostomy dependence, and depression. The resident's current orders specified an NPO diet and the use of chlorhexidine gluconate solution for oral care, to be administered with a swab and not ingested. Despite these orders and facility training that outlined the correct procedure for providing oral care to NPO residents—including the use of a foam swab soaked in chlorhexidine and the avoidance of giving liquids by mouth—a nurse poured a small amount of the solution directly into the resident's mouth to clean her teeth. This action was confirmed through medical record review, staff interviews, and facility documentation, indicating a failure to adhere to established protocols for NPO residents.