Failure to Update Care Plan for Resident's Dental Status
Penalty
Summary
The facility failed to revise a resident's care plan to accurately reflect their current dental status. The resident, who was admitted with diagnoses including Type II Diabetes, Depression, and Hypertension, reported that their dentures did not fit properly upon admission and that a dental visit for realignment had not resulted in the return of the dentures. Despite the resident no longer having dentures, the care plan continued to list interventions related to denture care, such as ensuring proper fit and secure placement. Record review showed that the care plan had not been updated since its initiation, and there was no documentation in the medical record regarding the current status of the dentures. The Director of Nursing acknowledged that the care plan was outdated and did not reflect the resident's present condition. The facility's policy requires that care plans be reviewed and revised as necessary by the interdisciplinary team, but this was not done in this case.