Failure to Provide Required Morning Oral Hygiene Assistance
Penalty
Summary
The facility failed to provide or offer required oral hygiene during the morning routine for one resident who was dependent on staff assistance. Facility policy on oral hygiene, last reviewed in May 2021, required oral care every morning and at bedtime. The resident, admitted in late December 2024, had diagnoses including hemiplegia and hemiparesis following a stroke affecting the right dominant side, dysphagia, and dementia, and was assessed on the MDS as rarely or never understood, rejecting care on one to three days during the assessment period, and requiring supervision to complete oral hygiene. The resident’s comprehensive care plan included an intervention for assistance of one staff member for dressing and hygiene, and a nursing order dated July 2025 directed staff to assist with tooth brushing every morning and night, with refusals to be documented in progress notes. Progress notes from October 2025 through early January 2026 documented refusals of oral care only on two dates in October. A dental visit note from late October 2025 described the resident’s oral hygiene as very poor, with heavy plaque and food debris and moderate tartar accumulation, and stated that the resident’s special needs rendered them incapable of maintaining adequate oral health without daily assistance, encouraging staff to assist with tooth brushing. On a morning in early January 2025, observation showed the resident in their bedroom with food debris in their mouth. A subsequent continuous observation of the resident’s morning care showed a nursing assistant assisting the resident out of bed, dressing them, styling their hair, and cleaning and donning their eyeglasses, but not offering or providing assistance with tooth brushing. In an interview immediately afterward, the nursing assistant confirmed that oral hygiene was not performed or offered and acknowledged it should have been part of the resident’s morning care.
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