Failure to Provide Ordered Oral Hygiene for Dependent Resident
Penalty
Summary
The facility failed to ensure that a resident who was unable to perform activities of daily living received necessary oral hygiene care as outlined in the care plan. The resident was admitted with diagnoses including sequelae of cerebral infarction, acute respiratory failure with hypoxia, aphasia, tracheostomy, and gastrostomy, and had an ADL self-care performance deficit related to cardiovascular accident and respiratory failure. The care plan specified an oral care routine in the morning and at night, including brushing teeth, cleaning gums with a toothette, and rinsing the mouth. An MDS assessment showed a BIMS score of 00, indicating severe cognitive impairment, and documented that the resident was dependent on staff for oral hygiene. On observation, the resident was noted to have a tracheostomy and lips covered with white debris, and the respiratory therapist acknowledged that oral care was needed and stated that CNAs were responsible for providing oral care and that it should have been done. An LPN reported that she cared for the resident and that the resident did not receive oral care the previous day and was unsure how often CNAs provided oral care. A CNA stated she did not provide oral care because she believed the respiratory therapist did so. The ADON confirmed that oral care was in the resident’s plan of care, that CNAs were responsible for providing oral care every shift, and that the resident should have received oral care, demonstrating that the ordered oral hygiene interventions were not carried out as required.
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