Failure to Accurately Care Plan for Denture Use and Oral Care Needs
Penalty
Summary
The facility failed to ensure that the care plan for a resident accurately reflected her oral care needs, specifically regarding her use of dentures. Despite documentation in the dental record that the resident had full top and bottom dentures, including a broken tooth on the upper denture and a recent dental cleaning, the comprehensive care plan and MDS assessment did not indicate that the resident had dentures or required related care. The care plan also did not address the resident's refusal to wear her dentures or her preferences regarding their use. Observations and interviews revealed that the resident kept her dentures in her backpack and was often seen without them, including during meals. The resident expressed concern about her appearance without dentures and stated she was advised not to use them until the broken tooth was repaired. Staff interviews indicated a lack of awareness about the resident's denture status, with some staff unsure if she wore dentures and others unaware of the broken denture. Documentation of denture care and refusals was inconsistent, and staff did not consistently communicate or document the resident's preferences or refusals regarding denture use. The facility's policy required that care plans describe all services provided to maintain the resident's well-being, including documenting refusals and informing the resident of risks and alternatives. However, the care plan did not reflect the resident's denture use, her refusal to wear them, or the need for assistance with denture care, despite clear evidence from dental records, staff, and family interviews that these needs existed.