F0684

D

Failure to Follow Splint and Denture Care Orders for Two Residents

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

Penalty

No penalty information released

Summary

Facility staff failed to follow physician orders for splint placement for one resident with upper extremity contractures. The resident had dementia with psychotic disturbance, seizure disorder, a colostomy, and documented impairments in both upper and lower extremities. A physician’s order directed that the resident wear a left elbow extension splint on the left upper extremity for three hours, and the care plan required staff to check the extremity and skin beneath and adjacent to the splint regularly. On one observation day, the resident was seen in bed with the left arm splint in place in the morning and still in place several hours later in the afternoon, suggesting the splint remained on beyond the ordered three-hour period. In a later interview, the restorative aide/CNA reported that staff typically put the splint on between 7:00–8:00 a.m. and removed it between 1:00–2:00 p.m., and acknowledged that removal was not documented and that she was unaware of the specific ordered wear time for this resident.

Facility staff also failed to consistently assist another resident with the application and management of dentures as ordered and care planned. This resident had multiple diagnoses including dysphagia following cerebral infarction, type 2 diabetes with autonomic neuropathy, heart failure, glaucoma, major depressive disorder, morbid obesity, and generalized muscle weakness, and required substantial/maximal assistance with oral hygiene and denture management per the MDS. Physician orders and the care plan directed staff to assist and encourage the resident to place full upper and lower dentures on during the day shift, remove them during the evening shift, check denture fit while the resident was awake, assist with washing dentures, and place them in a denture cup with tablet at bedtime, as well as to obtain dental consults per policy and as needed.

Despite these orders and care plan interventions, multiple observations over several days showed the resident awake in bed without dentures in place. The resident reported that staff helped her rinse her mouth and put in dentures but that she had not been wearing them lately because they hurt and did not fit properly, and that she wanted new dentures to be able to eat other foods. She also stated that no staff had offered to schedule a dental appointment to address the fit issues. Review of the treatment administration records showed staff had documented that they were assisting with denture placement, removal, fit checks, and cleaning, even though the resident was repeatedly observed without dentures. A CNA on the evening shift stated she did not know the resident had dentures and had never seen her with them. The unit manager/RN confirmed there were physician orders and a dental care plan for dentures and stated she was not aware of any issues with denture fit until speaking directly with the resident, and acknowledged that no nursing staff had reported denture fit problems despite the existing orders and care plan.