Failure to Document and Track Resident's Dentures
Penalty
Summary
The facility failed to ensure that a resident's right to retain and use personal possessions was honored when a set of dentures delivered to the resident was neither documented in the inventory records nor subsequently located. The resident, who had diagnoses including anxiety disorders and altered mental status, was admitted with a process in place for documenting personal belongings. However, review of the resident's records showed that the dentures, delivered by a dental provider, were not entered into the inventory of personal effects, and there was no record of their loss in the theft and loss log. Multiple staff interviews confirmed that the inventory list had not been updated since admission, and the required procedures for documenting and tracking personal items were not followed. Observations of the resident revealed a sunken facial appearance, and staff interviews indicated that packages and personal items are typically logged, labeled, and added to the inventory list. Despite these procedures, the dentures were not accounted for, and staff responsible for maintaining these records were unaware of the missing item. Review of facility policies confirmed that all personal items, especially those affecting health and safety, should be documented and tracked, but these policies were not adhered to in this case.