HospitalInspections.org

Based on document review, medical record review and interview it was revealed the facility failed to ensure facility policy and physician orders were followed by not providing oral care as ordered for four (4) of ten (10) patients (patients #1, 6, 8 and 10). This failure has the potential to cause an increase in the probability of mouth sores and infection in susceptible patients.

Findings include:

1. A review of the facility policy entitled "Guidelines and Protocols, Clinical," last revised date 7/1/21, revealed in part: "Routines/Guidelines: Hygiene: Oral care minimum frequency: BID and PRN; Oral care for NPO tube feedings; minimum frequency - Every 4 hours ..."

2. A review of patient #1's medical record revealed the patient had been ordered strict NPO (nothing by mouth) because of dysphagia and was receiving tube feedings. The patient also had an order for "Oral care four times a day." Documentation in the medical record from 10/8/21 to 10/27/21 revealed oral care was not provided four (4) times a day as ordered.

3. A review of patient #6's medical record revealed an order for "Oral care four times a day." Documentation in the medical record from 10/11/21 to 11/2/21 revealed oral care was not provided four (4) times a day as ordered.

4. A review of patient #8's medical record revealed an order for "Oral care four times a day." Documentation in the medical record from 10/28/21 to 11/3/21 revealed oral care was not provided four (4) times a day as ordered.

5. A review of patient #10's medical record revealed an order for "Oral care four times a day." Documentation in the medical record from 10/6/21 to 10/28/21 revealed oral care was not provided four (4) times a day as ordered.

6. An interview was conducted with the Director of Quality on 11/3/21 at 11:20 a.m. and she agreed with the above findings.