What is the consequence of not recording oral care performed on a resident?

Not recording oral care performed on a resident can lead to serious legal implications. Documentation is a vital part of the caregiving process, as it ensures clear communication regarding the care provided, which is essential for maintaining the health and safety of residents. If oral care is not recorded, it may appear that the care was not provided, which can lead to misunderstandings or disputes over the resident's care. This lack of documentation could also expose the healthcare provider or facility to liability if there are issues related to the resident's oral health or overall wellbeing. Proper documentation helps to protect both the resident and the caregiver by providing a record of care that can validate the actions taken during a shift. Thus, failure to document care activities accurately can have significant legal repercussions.