Failure to Provide Denture Care and Denture Use Prior to Meal Service
Penalty
Summary
The facility failed to ensure oral care and denture use were provided before breakfast for one resident who required assistance with activities of daily living. The resident had diagnoses including dysphagia following a stroke and type 2 diabetes, and an MDS assessment showed a BIMS score of 8, indicating severe cognitive impairment, with a documented need for substantial assistance with oral hygiene. Physician orders indicated the resident was dependent with all meals. During observation, the resident was sitting up in bed being fed breakfast by a CNA, while an open denture cup containing dentures was on the nightstand. The CNA stated she did not know the resident wore dentures and had not provided oral or denture care prior to breakfast, and she continued feeding the resident without placing the dentures in the resident’s mouth. In an interview, an LN stated the resident should have been assisted with placing dentures in the mouth before eating breakfast and that it was important for the resident to wear dentures while eating to chew food and avoid choking. In a telephone interview, the DON stated her expectation was that dentures were placed in the resident’s mouth prior to every meal so residents could consume an adequate amount of food and the texture they like, and stated, "We don't want them to choke or aspirate." Review of the facility’s “Dentures, Cleaning and Storing” policy indicated denture care was to be provided before breakfast and at bedtime, and residents were to be encouraged to keep dentures in their mouths as much as possible. The “Dental Services” policy indicated direct care staff would assist residents with denture care, including removing, cleaning, and storing dentures.
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