Failure to Document and Timely Coordinate Denture Services
Penalty
Summary
The facility failed to provide medically appropriate dental services by not ensuring complete and timely documentation and follow-through of denture services for one resident. The resident was observed in bed with a denture cup at the bedside, and a social service progress note documented that the resident’s guardian had provided contact information and requested that the resident be assessed and fitted for dentures. However, review of the clinical record did not show that the resident had been assessed and fitted for dentures, despite this request. E-mails from the dental provider, supplied by the social service director, showed that impressions for upper and lower dentures were made, that the resident received upper and lower dentures with no adjustments initially needed, and that the dentures were later adjusted for comfort with instructions given on denture care. The resident stated their dentures were in their denture cup. The social service director, who began working at the facility months after the initial request, reported there was no documentation in the clinical record regarding these dental services, even though they found e-mail communications from the dental provider. The social service director also stated they did not know why the information was not included in the clinical record or why it took more than a year before the resident received dentures.
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