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Liability Landscape

April 1, 2006
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Don't Overlook Your Residents' Oral Health by Linda Williams, RN
LIABILITY landscape

Don't overlook your residents' oral health According to the Surgeon General's 2000 report on oral health in America, there is a connection between poor oral care/chronic oral infections and diabetes, heart disease, lung disease, pneumonia, stroke, and other health concerns primarily affecting the elderly. Unplanned weight loss also can be associated with oral health related to fractured or carious teeth, as well as poorly fitting or missing dentures.

Unfortunately, seniors who live in nursing homes are at greater risk for oral health problems than those who live independently. Much of the resident care at nursing homes is medically centered, and sometimes oral health needs get overlooked. Facility workers may struggle with squeezing good oral hygiene into an already demanding routine. A lack of training for aides and resistance from some residents also contribute to inattention to oral hygiene. Additionally, facilities may have difficulty finding a dentist willing to service residents because of low Medicaid reimbursement and discomfort in seeing medically compromised residents.

The importance of oral health is fundamental to a resident's general health and quality of life. Caregivers need to be vigilant in assessing and providing for the oral health needs of their residents, to the extent that they are able. Families, in turn, also should be diligent in preserving their loved ones' oral health. The following situation involves the tragic consequences that occurred when a man's oral health needs were not met. Please take the time to review the circumstances surrounding the situation and make changes as appropriate in your facility.

The Situation
An 80-year-old man with a history of tongue cancer, anemia, cachexia, and COPD was admitted to a nursing home for medical care. The man could make his own decisions, but communicated poorly because of his compromised state. He had both upper and lower partial dentures and suffered from choking episodes and a decreased appetite, both of which affected his ability to eat and feed himself.

Four days after his admission, the man communicated to the nursing staff that he was choking. The nurse's assessment revealed that his airway was clear, but he appeared anxious and had a very difficult time swallowing. In fact, his eyes watered heavily while swallowing. The nurse immediately notified his physician, who advised sending the man to an urgent care clinic. The social services director accompanied the man to the clinic with a transfer sheet stating his chief complaints were "choking, hard to swallow, becomes tearful."

At the clinic, the man told the physician that his neck hurt. However, the physician noted that the man was lying down with no acute distress. The physician's exam revealed nothing out of the ordinary, except a neck deformity from a previous surgery and the fact that the man's throat was red; it later tested positive for a yeast infection. The man was given an antifungal medication, told to drink only liquids, and was transferred back to the facility.

Throughout that afternoon, the man continued to exhibit restless behavior by climbing in and out of his bed frequently. He refused to drink fluids and soon developed a congested cough. He told the next shift nurse that he was unable to "cough it up," but didn't expound further. The man's family came to visit him and expressed concern for his health. As hours passed, the man's heart rate and blood pressure began to rise, and his breath sounds diminished and oxygen saturation rate dropped to 86%. The nurse contacted his physician again and soon the resident was transported back to the clinic with a written history detailing his condition throughout the day. The same physician met the man at the clinic and sent him to the hospital for admittance.

At the hospital, a chest x-ray was ordered and the hospital physician diagnosed the man as having lower lobe pneumonia, so he was placed in the ICU for further x-rays and evaluation. A week passed and the man's condition worsened; an ENT consult was ordered. During laryngoscopy, the man's upper denture was discovered lodged above his vocal folds. The surgeon immediately extricated the denture, but the man died of respiratory failure and aspiration pneumonia four days later.

Two years passed before the facility received notification that it was being sued by the man's family for his wrongful death. The hospital's treating physicians and radiologist also were named on the lawsuit. As the suit progressed, virtually all of the plaintiff's expert witnesses were critical only of the man's hospital care, except one nurse who criticized the facility for failing to investigate and locate the man's upper denture after he complained of choking. She also criticized the staff for failing to tell the physicians they had not removed or secured the man's dentures.

The facility's response to the nurse's criticisms was that the man was new and they were still getting to know his behaviors. It is quite common to have residents who choose not to wear dentures at all times, which is their choice. The man was cognizant and did not communicate to them that he had swallowed a foreign object. Furthermore, a visual inspection of his airway was conducted without any visible foreign objects noted. The lawsuit was eventually settled out of court, with the facility contributing a minimal amount to the final award.

Risk-Management Steps to Protect Your Residents and Facility