Failure to Revise Care Plan for Denture Storage After Multiple Losses
Penalty
Summary
The facility failed to revise the care plan for a resident with severe cognitive impairment and an activated healthcare power of attorney to address the safe storage of the resident's dentures, despite multiple incidents of the dentures being lost. The resident, who requires partial assistance with activities of daily living and has a history of hemiplegia, hemiparesis, vascular dementia, and anxiety, had a care plan that only included reminders to put on and remove dentures but did not specify interventions for their secure storage. Nursing documentation indicated that the dentures were lost on two separate occasions, with the facility only able to recover them after the first incident. Interviews with staff revealed inconsistent practices regarding denture storage, with options including keeping dentures in the resident's bathroom or in the medication cart, depending on resident or family preference. Despite these incidents and the facility's policy requiring care plans to be reviewed and revised as needed, the care plan was not updated to include specific interventions for denture storage. The deficiency was identified during a survey when it was noted that the care plan did not reflect the resident's needs and preferences regarding denture management.