Incomplete and Inaccurate Clinical Record Documentation for Denture Care
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for one resident. A quarterly MDS assessment indicated that the resident was able to communicate and had a diagnosis of diabetes. A dental summary documented the insertion of lower complete dentures and that care instructions were provided. However, during an interview and observation, the resident was found to have no natural teeth and was not wearing dentures, stating that his dentures were broken and unavailable. Review of nurse aide documentation over several months showed inconsistent entries regarding denture care, with some shifts marked as 'not applicable/refused' and others as 'yes.' A nurse aide clarified that she marked 'refused' or 'not applicable' because the resident did not have dentures to care for, not because the resident refused care. The DON confirmed that the documentation was inaccurate, as the resident's dentures were lost, and the records did not reflect the actual situation.