Failure to Review and Revise Comprehensive Care Plan for Dental Conditions
Penalty
Summary
The facility failed to ensure that comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment and as needed, as required by facility policy. Specifically, for one resident with diagnoses including diabetes mellitus, anemia, and heart failure, the care plan for oral/dental conditions was not reviewed or updated after quarterly assessments, despite the presence of dental issues such as cracked and missing teeth. The care plan, which included interventions like monitoring for oral infections and food intake, was last reviewed several months prior to the survey, and there was no documentation of review or revision following subsequent quarterly assessments. Observations revealed that the resident had cracked teeth but reported no mouth pain at the time. Nursing notes indicated an incident where a tooth fell out, and although attempts were made to secure a dental appointment, there was no evidence that the care plan was updated in response to this event. Interviews with staff revealed a lack of knowledge and follow-through regarding the review and revision of care plans, with the unit manager stating they did not check or revise care plans and the DON confirming that care plans should be updated at specific intervals and after significant changes, which did not occur in this case.