Observations
Based on a review of client records, the facility failed to document dental referrals in one of one client records.
The findings include:
Four client records were reviewed on December 1, 2010. Three records did not indicate a need for a dental referral. The facility failed to assist the client in obtaining dental supportive services in one of one client record. This client record indicated a need for dental services, but the facility did not document that this need was being addressed.
In client record #2 the individual was admitted on November 12, 2010. The nursing assessment indicated a need for dental services. There is no documentation of a dental referral in the client record.
This was discussed with the clinical supervisor and the counselor December 1, 2010. It was confirmed that this was not documented.
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Plan of Correction
The Clinical Supervisor will instruct staff that if a client expresses medical concerns or medical concerns are identified by the staff, the staff will provide to the client names and telephone numbers for appropriate medical providers. They may also assist the client in securring an appointment if necessary. The Program Director will send out a memo regarding this matter today |