Failure to Address Dental and Oral Health Needs in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan that addressed all of a resident's identified needs, specifically omitting dental and oral health care. A cognitively intact female resident with a history of depressive disorder, anxiety, diabetes, and heart disease required assistance with oral hygiene and was undergoing a multi-step denture process. Dental records indicated the resident was edentulous with gingival inflammation and required new dentures, with specific instructions from the dentist for staff to assist with oral hygiene and denture care. Despite these documented needs and instructions, the resident's care plan did not include any goals or interventions related to dental or oral health. The resident reported ongoing issues with her dentures, including poor fit, discomfort, and inability to wear them, which affected her ability to eat and speak. She also experienced a broken tooth, which she attributed to not being able to wear her dentures, and reported this to both the social worker and nursing staff, but no follow-up or adjustments were made. Interviews with facility staff revealed a lack of awareness regarding the resident's dental issues and the absence of dental care planning. The LVN stated she would typically notify the social worker and physician if dental problems were reported, but was unaware of any issues for this resident. The CNA was not aware the resident wore dentures, and the Regional Director of Clinical Services acknowledged the omission of dental needs in the care plan. The facility's own policy required care plans to include measurable objectives and be updated with changes in condition, but this was not followed for the resident's dental and oral health needs.