Inaccurate Medical Record Documentation of Dentures
Penalty
Summary
The facility failed to ensure the accuracy of the medical record for one resident. The resident was admitted with multiple diagnoses, including congestive heart failure, anxiety, dementia, and prediabetes. Documentation in the medical record, including the Long Term Care Evaluation, indicated that the resident had both upper and lower dentures. However, observation and interviews revealed that the resident only had an upper denture and some natural teeth on the bottom, with missing lower teeth. The resident's daughter confirmed that the bottom denture had been discarded prior to admission and was not replaced, which was also corroborated by the DON and Administrator. Despite these facts, the medical record inaccurately documented the presence of both upper and lower dentures. The DON confirmed that the assessment stating the resident had both dentures was not accurate. The expectation was that nursing assessments should be complete and accurate, but this was not met in this instance, resulting in an inaccurate medical record for the resident.