Incomplete Documentation of Oral Hygiene Care
Penalty
Summary
The facility failed to maintain complete and accurate documentation of oral hygiene care for one resident. According to the facility's mouth care policy, the date and time of mouth care should be recorded in the resident's clinical record. Review of the clinical record for a resident with diagnoses including diabetes, dementia, and hypertension revealed multiple instances across various shifts where documentation of oral care was missing or marked as not applicable. Specifically, there were several days and shifts where no record indicated that oral hygiene was completed. The Director of Nursing confirmed during an interview that the clinical record lacked complete documentation for oral hygiene and acknowledged that such care should be performed and documented as ordered.