F0656

D

Failure to Care Plan for Allergies and Implement Denture Care Interventions

Washington, District Of Columbia Survey Completed on 03-12-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to develop and implement comprehensive care plan interventions for a resident’s documented allergies and another resident’s denture use and oral care. One resident was admitted with multiple diagnoses, including urinary tract infection, convulsions, dysphagia, hypertension, acute kidney failure, hemiplegia and hemiparesis following cerebral infarction, acute embolism and thrombosis of deep veins of the lower extremity, muscle weakness, altered mental status, morbid obesity, and age-related nuclear cataract. The resident’s MDS showed a BIMS score of 14, indicating she was cognitively able to participate in care decisions. The physician history and physical documented allergies to Motrin and tuna, but review of the comprehensive care plan showed no care plan developed to address these allergies.

During observation, this resident was lying in bed and stated she was allergic to tuna and believed the facility was providing her food containing tuna, which she associated with experiencing an allergic reaction and a rash on her face. She showed no signs of distress at the time of observation. Staff interviews revealed that the 1st floor RN unit manager believed the tuna allergy was listed on the resident’s meal ticket but needed to verify this with the food operations department. The dietician explained that residents’ food preferences are entered into an electronic dining system that generates meal ticket information, and that preferences are obtained during the initial assessment and baseline care plan and reviewed every three months, with documentation in the care plan and dietician notes. The RN charge nurse stated she had never heard the resident complain about food allergies but knew of the tuna allergy from completing the admission assessment. The DON stated that medication and food allergies should be assessed and documented during admission and later acknowledged that the resident should have a care plan addressing her allergies. The facility did not have such a care plan in place until after surveyor inquiry.

The second part of the deficiency concerns another resident admitted with dysphagia following cerebral infarction, type 2 diabetes mellitus with diabetic autonomic polyneuropathy, heart failure, primary open-angle glaucoma, major depressive disorder, morbid obesity, and generalized muscle weakness. This resident was observed multiple times awake in bed watching television, with a denture cup at the bedside but not wearing dentures. The resident reported needing staff assistance with oral care and denture placement, stated that the dentures did not fit properly, caused pain, and that she had not been wearing them lately. She reported having received new dentures a few months earlier after losing her old ones and stated that the facility was aware of her concerns. Record review showed multiple physician orders for dental consults, denture care, and specific instructions to assist and encourage the resident to place and remove full upper and lower dentures, check denture fit while awake, and ensure dentures were rinsed and stored properly.

The resident’s care plan documented impaired dentition related to using dentures, with goals for clean teeth and healthy gums and interventions including assessing and documenting the resident’s ability to perform dental care, assisting as needed, obtaining dental consults per policy and as needed, modifying diet as needed, monitoring oral intake, assisting and encouraging denture use during AM and PM care, checking denture fit, and checking linens and other areas if dentures were missing. A quarterly MDS showed intact cognition with a BIMS score of 15, upper extremity impairments, and a need for substantial/maximal assistance with oral hygiene, including denture management. The TAR for the review period documented that staff were carrying out the ordered denture-related interventions; however, observations on several dates showed the resident not wearing dentures and reporting that they hurt and that she had not worn them for months. An evening-shift CNA stated she did not know the resident had dentures and had never seen her wearing them. The RN unit manager confirmed the existence of a dental care plan with interventions to assist with dentures but stated she was not aware of any issues with denture fit until speaking directly with the resident, who reiterated that the dentures did not fit and were painful. These findings showed no evidence that staff implemented the resident’s dental care plan interventions.