Failure to Track and Replace Lost Dentures for Two Residents
Penalty
Summary
The facility failed to track, locate, replace, and follow up on lost dentures for two residents, resulting in both individuals being without their dentures for an extended period. One resident, admitted for heart failure and with intact cognition, required assistance with oral hygiene and had upper dentures on admission. Her dentures were lost approximately two months prior to the survey, and despite repeated inquiries, the facility did not provide updates or facilitate replacement, leaving her to eat only soft foods and feel blamed for the loss. The resident reported emotional distress due to the situation, and staff confirmed awareness of the missing dentures but had not resolved the issue. Another resident, admitted with cerebral infarction and end-stage renal disease on hemodialysis, also required assistance with oral hygiene and had both upper and lower dentures on admission. His dentures were lost, and although a dental appointment was scheduled, neither he nor his family received follow-up communication from the facility. The resident was forced to use ill-fitting temporary partials, which impaired his ability to eat and speak, and negatively affected his social interactions and self-esteem. Staff interviews revealed a lack of a tracking log for lost dentures and uncertainty about whether the issue was discussed in interdisciplinary meetings. The facility's policy required investigation and documentation of lost property, but this process was not followed for these cases.