Failure to Ensure Timely Dental Services Due to Inaccurate Documentation
Penalty
Summary
A resident with unspecified dementia and severe cognitive impairment was admitted to the facility with both upper and lower dentures, as documented on the Inventory Sheet of Personal Effects. However, the resident's clinical record and nursing assessments failed to accurately document the presence of dentures, instead indicating she had her own natural teeth and no dental concerns. The resident required maximum assistance or was totally dependent on staff for oral care. Several weeks after admission, the resident's lower denture went missing, but this was not identified or addressed by facility staff. The resident reported the loss to her husband but was unsure if it was communicated to the facility. The missing denture was only discovered after surveyor inquiries, and until that point, the resident had adapted by eating a soft, bite-sized diet. The Director of Nursing confirmed that the facility failed to recognize the missing denture due to inaccurate documentation at admission and did not ensure timely and necessary dental services for the resident.