Failure to Care Plan and Implement Denture-Related Oral and Nutritional Care
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for all residents reviewed, specifically neglecting to address oral care needs related to denture use and associated interventions for oral and nutritional maintenance. This deficiency was identified for 27 residents, including one resident who experienced significant weight loss and impaired nutritional status due to the lack of assistance with denture use, despite system-generated warnings and lab results indicating low protein levels. The care plans for these residents did not include measurable objectives or timeframes to address their medical, nursing, and psychosocial needs, nor did they describe the services required to help residents attain or maintain their highest practicable well-being. Multiple residents who required assistance with dentures were not identified as such in their care plans, and staff were often unaware of residents' denture needs. For example, one resident with a history of cerebral aneurysm, depression, and hypertension, who had no natural teeth and required supervision or touch assistance with oral care, was not provided with the necessary support to use her dentures. Despite repeated expressions of frustration and requests for help, she was left to eat a limited diet of soft foods, resulting in ongoing weight loss and dissatisfaction with her care. Staff interviews revealed a lack of awareness and communication regarding residents' denture status, with CNAs and dietary staff relying on verbal cues or incomplete documentation rather than care plans or shift sheets. The deficiency was further evidenced by the absence of documentation addressing system-generated alerts for significant weight loss, as well as the lack of updates to care plans when residents received dentures after admission. Interviews with staff, including CNAs, nurses, and the MDS coordinator, confirmed that denture use was not consistently included in care plans, and there was confusion about responsibility for updating this information. As a result, residents who required assistance with dentures did not receive appropriate support, placing them at risk for impaired nutritional status and unmet care needs.