Failure to Notify Legal Guardian of Missing Dentures for Incapacitated Resident
Penalty
Summary
The facility failed to notify a court-appointed legal guardian of a significant change involving missing dentures for a resident who had been determined totally incapacitated. The resident was admitted with dementia with behavioral disturbances, and a court determination dated 10/26/23 documented the resident’s total incapacity related to dementia and lack of awareness. On 8/8/24, a legal guardian of person and property was appointed, and the guardian’s name, phone number, and email address were documented in the admission record. The resident’s inventory list dated 7/29/24 showed that the resident had upper dentures, and a monthly summary progress note on 1/19/26 indicated the resident wore dentures or partials. On 1/27/25 at 12:24 PM, the resident was observed in the dining room for lunch without dentures in place. During a phone interview on 1/28/26 at 3:40 PM, the legal guardian reported being unaware that the dentures were missing and stated the facility had never notified her of this issue. On 1/29/26 at 10:05 AM, the Executive Director stated that staff believed the dentures had been missing for approximately three weeks and acknowledged that the guardian had not been notified because dentures often go missing for a few weeks before turning up again. Review of the facility’s “Notification of Changes” policy showed that when a resident is deemed incapacitated, the resident’s representative is to be notified so that they can make necessary decisions, which did not occur in this case.
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