Failure to Refer Resident for Replacement of Lost Dentures
Penalty
Summary
The facility failed to promptly refer a resident with lost partial dentures to dental services, resulting in the resident going without his upper partial denture. The resident, who had Alzheimer's disease and severe cognitive loss, was on a pureed diet and expressed dislike for the texture. The loss of the partial denture was discovered when the resident's family came to pick him up for a home visit, and staff informed them that the denture was missing. Documentation showed that the denture was reported missing, and a search was conducted, but there was no evidence that a referral to dental services was made or that replacement was offered. Review of the resident's records indicated a significant weight loss of 15% over six months. The facility's policy stated that it is responsible for lost dentures when the resident is not competent or has dementia. However, staff interviews revealed that some were unaware the denture was missing, and no documentation was provided to show follow-up or referral to dental services before the end of the survey.