Failure to Obtain Timely Dental Services After Loss of Denture
Penalty
Summary
The deficiency involves the facility’s failure to assist a resident in obtaining timely dental services after the loss of an upper denture, contrary to its own Dental Services Policy requiring referral within three days for lost or damaged dentures. The resident, who had dementia and chronic kidney disease, was documented on December 22, 2025, as having a missing upper denture that could not be located despite staff searching her room. Her care plan included an intervention to obtain a dental consult as needed, and there was a physician order allowing dental visits as needed. However, no dental referral was made until January 23, 2026, more than a month after the denture was reported missing, and the resident was not seen by a dentist for an impression for a new upper denture until February 2, 2026. During this period, multiple speech therapy notes documented that the resident had decreased meal intake and difficulty chewing due to the missing denture, leading to a downgrade to a puree diet, which she refused, and then to a mechanical soft diet. The resident repeatedly complained about her inability to chew mechanical soft textures and expressed to staff and family that she disliked the softer diet and wanted dentures so she could eat regular food again. Observations showed her eating without her upper denture, and interviews with the Speech Language Pathologist confirmed that the resident continued to voice a desire for new dentures. Weight records showed a decrease from 191.6 pounds on January 9, 2026, to 184.2 pounds on March 2, 2026, after the denture went missing. The DON stated she would expect residents to receive timely dental consultations for missing dentures.
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