Failure to Revise Dental Care Plan After Change in Resident's Dental Status
Penalty
Summary
The facility failed to review and revise the dental care plan for one resident after the completion of the Minimum Data Set (MDS) assessment and following a change in the resident's dental status. The resident, who had diagnoses including hemiplegia, hemiparesis, dysphagia following a stroke, and major depressive disorder, was dependent on staff for oral hygiene and had no natural teeth. The care plan, dated several months prior, indicated the resident had a broken upper denture and included an intervention for the resident to refrain from using the upper denture until it was fixed. Subsequent documentation showed that the resident's upper denture was repaired and delivered, and later evaluations confirmed the resident had both upper and lower dental appliances. Interviews with staff confirmed that the resident wore both dentures daily and that staff assisted with their care. However, a review of the medical chart with the Director of Nursing revealed that the care plan had not been updated to reflect the repaired denture and the resident's current dental status, despite facility policy requiring care plan revisions after assessments and changes in condition.