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F0791
E

Failure to Ensure Denture Availability for Residents

Erie, Pennsylvania Survey Completed on 02-04-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure the proper use and availability of dentures for two residents, leading to a deficiency in dental services. Resident R51, who has multiple sclerosis, Alzheimer's disease, and other conditions, was admitted with upper and lower dentures. Despite a dental evaluation confirming the dentures fit well, the resident later reported missing upper dentures, and the facility had not initiated any investigation or follow-up to replace them. Resident R187, admitted with cerebral infarction and other diagnoses, had an upper partial denture upon admission. The partial went missing shortly after admission, and despite efforts to locate it, including searching the resident's room and garbage, it was not found. The facility did not conduct an investigation or follow-up to replace the missing partial. Interviews with the Nursing Home Administrator confirmed the lack of action taken to address the missing dentures for both residents. The facility's failure to promptly refer residents for dental services or document efforts to ensure adequate nutrition while awaiting replacement dentures contributed to the deficiency.

Plan Of Correction

Resident #51 appointment was made by administrator/designee. Resident #187 is no longer a resident at the facility. All residents were reviewed to ensure that their dental needs are met by the Director of Nursing or designee, which included missing dentures and dental needs. Social Service and nursing staff were educated on the Care of dentures policy and making appointments in a timely manner by the Director of Nursing/designee. An audit will be conducted weekly for 4 weeks and then monthly ongoing to ensure that residents that required dental care to meet their needs, including residents that have missing or ill-fitting dentures, will be addressed as per policy by the Director of Nursing/Designee. Residents will be interviewed weekly by Social Services or designee to ensure dental concerns are being addressed weekly for 4 weeks, then monthly ongoing. Findings will be reported to the Quality Assurance Performance Improvement committee for review and recommendations.

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