Failure to Provide Oral Hygiene for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident who was severely cognitively impaired and dependent on staff for all activities of daily living, including oral hygiene, did not receive oral care as required. The resident, who had diagnoses including metabolic encephalopathy, dysphagia, and depression, was observed in bed with visible traces of food or milk on the gums after breakfast. The certified nurse assistant (CNA) responsible for the resident confirmed that oral care had not been provided that morning, despite it being her responsibility and an intervention listed in the resident's care plan. Interviews with facility staff, including a licensed vocational nurse (LVN) and the Director of Staff Development (DSD), confirmed that the resident was dependent on staff for oral hygiene and that oral care should have been provided after meals. Review of the facility's policy and procedures indicated that residents unable to perform activities of daily living independently must receive necessary services, including oral hygiene, in accordance with their care plan. The failure to provide oral care as required constituted a deficiency in the facility's provision of necessary care and services.