Failure to Provide Required Setup Assistance With Oral Hygiene and Denture Care
Penalty
Summary
The facility failed to provide required setup assistance with oral hygiene for a resident with thoracic vertebrae fractures, weakness, and pain who had an identified self-care performance deficit. The resident’s Kardex and activities of daily living care plan, revised on 1/9/26, specified that routine oral care included brushing teeth, rinsing dentures, cleaning gums, rinsing with mouthwash, and that the resident required partial to moderate setup assistance with oral care. The admission MDS documented intact cognition, impaired upper extremity range of motion bilaterally, and a need for setup or clean-up assistance with oral hygiene. Despite these documented needs and instructions, the resident reported not recalling the last time setup assistance for oral care was provided and was unsure if a denture cup was available. On observation, the resident’s upper denture had a visible buildup of white-colored substance on the gums and teeth, and no denture cup was found in the resident’s room or bathroom. The NA assigned to the resident on two consecutive day shifts stated that the resident had his own teeth and could brush independently, reported providing setup assistance by positioning the resident and handing over a toothbrush and toothpaste, and stated she was unaware the resident had an upper denture, noting there was no denture cup in the room. A subsequent observation showed no change in the denture’s condition. During an interview and observation, the DON confirmed the presence of an upper denture, the continued buildup on it, and the absence of a denture cup, and stated that oral hygiene, including brushing teeth and dentures, was to be done daily. The Administrator stated she expected NA staff to review the Kardex to know if a resident had dentures and to offer daily oral hygiene, and that the assigned NA should have been aware of the upper denture and the need for setup assistance.
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