Failure to Develop and Implement Comprehensive Oral Care Plan
Penalty
Summary
The facility failed to develop and implement a person-centered, comprehensive care plan that adequately assessed and addressed the dental status and oral care needs of a resident. Observations revealed that the resident was lacking teeth and relied on dentures, which had been lost by the facility and replaced by an old pair provided by family. Interviews with staff indicated inconsistent practices regarding oral and denture care, with some staff believing that if dentures were already in place, oral care was unnecessary. The resident's care plan did not specify whether the resident had no teeth or dentures, nor did it outline the specific type of oral care required. Further interviews with family members revealed that the facility had not replaced the lost dentures as expected, and that family members had to clean the resident's dentures themselves due to staff neglect. The facility's policy required comprehensive, person-centered care plans that included resident-specific interventions, but the care plan for this resident lacked essential details about dental status and oral care needs. Documentation and communication regarding refusals of care and the resident's oral health status were also found to be insufficient.