Failure to Provide Adequate ADL and Oral Hygiene Care for a Dependent Resident
Penalty
Summary
The facility failed to provide necessary ADL care, including grooming and personal and oral hygiene, for a dependent resident who required staff assistance. The resident had a traumatic brain injury, dysphagia, and a BIMS score of 8 indicating moderate cognitive impairment, and was dependent on staff for ADLs such as oral and personal hygiene per the MDS. During observation, the resident was in bed receiving GT feeding with an oily-appearing face and pale, white dry matter noted between the upper roof of the mouth and tongue and between the upper and lower teeth. The LVN present acknowledged that the resident required oral care and stated that the resident’s oral care involved suctioning, which was the responsibility of licensed nursing staff. Additional observations throughout the same day showed that the resident’s basic hygiene needs remained unmet. A CNA stated that the resident’s face needed to be washed and shaved, and later, in the presence of the Infection Preventionist, crust-like matter was observed stuck between the resident’s left upper and lower eyelids, and the Infection Preventionist stated the resident’s eyes needed to be cleaned. The Unit Manager later stated that oral and personal hygiene should be provided at least twice daily and as needed, and that both licensed staff and CNAs were responsible for ensuring residents received proper ADL care. The facility’s policy on ADL care for dependent residents indicated that residents unable to carry out ADLs should receive necessary services to maintain grooming and personal and oral hygiene.
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