Failure to Provide Adequate Oral Hygiene for Dependent Residents
Penalty
Summary
The facility failed to provide adequate oral hygiene to three out of five sampled residents who were dependent on staff for activities of daily living. Observations revealed that these residents had visible signs of poor oral care, such as thick, white secretions, white crusty discharges, and dry, cracked lips. Interviews with staff and residents confirmed that oral care was not consistently provided as required by the residents' care plans and facility policies. Resident 2, who had diagnoses including hemiplegia, hemiparesis, diabetes, and hypertension, was observed with thick, white secretions in the mouth and reported that nurses did not provide daily oral care. Resident 3, with severe cognitive impairment and similar physical limitations, was found with white crusty discharges on the lips, and staff acknowledged that oral care was difficult but still necessary. Resident 4, also dependent on staff and with severe cognitive impairment, was observed with dry, crusty mucus on the lips, and staff noted that moisturizer was not always applied as part of oral care. Record reviews for all three residents showed that their care plans required daily and every shift oral care, including the use of oral care kits with Chlorhexidine Gluconate, brushing teeth twice daily, and moisturizing the lips. Despite these documented interventions, the observed conditions and staff interviews indicated that these measures were not consistently implemented, resulting in poor oral hygiene for the affected residents.