Failure to Ensure Dental Referral for Resident
Summary
The facility failed to ensure a dental oral surgery referral was made for a resident who required extractions of fractured teeth. The resident, who was admitted with diagnoses including pain and dysphagia, had a BIMS score indicating intact cognition. A dental evaluation in February recommended referral to an oral surgeon for surgical extractions of teeth #2 and #19 due to discomfort from fractured teeth. A subsequent evaluation in April reiterated the need for extraction of tooth #19, which was non-restorable and causing pain. Despite these recommendations, the necessary referral was not made. The resident expressed ongoing pain and concern about the lack of assistance from the facility in addressing their dental needs. A progress note from July indicated that the resident was unable to be seen by a dentist without a guardian present, and the appointment needed to be rescheduled. The facility administrator acknowledged the lack of a social worker to make the referrals and mentioned that a new social worker had been recently hired. This oversight resulted in the resident continuing to experience dental pain without the required surgical intervention.
Penalty
Resources
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A resident with multiple chronic conditions and dementia reported missing dentures, which were later found broken in a toilet. The care plan directed staff to monitor for oral/dental problems and to coordinate dental care and transportation, and the guardian reportedly agreed to arrange for the resident to be seen by a dentist. However, over the following months there was no documentation of any dental visits or of attempts to contact the guardian regarding dental care, despite the requirement for a completed dental consent form. The SSD confirmed the lack of documentation of guardian contact and was unaware of any policy on the frequency of guardian contact to resolve such issues.
A resident with diabetes and anxiety lost several upper teeth during her stay and was not provided with a dental care plan or assistance in scheduling a dental appointment, despite expressing a desire to see a dentist. Staff confirmed no dental appointments had been arranged and no documentation of dental care planning was present.
A resident with a broken tooth and subsequent infection did not receive a timely follow-up dental appointment for root extraction. After an initial unsuccessful extraction and a referral for oral surgery, the resident was treated with antibiotics but was not scheduled for the necessary procedure. The scheduler left a message with the only Medicaid-accepting surgical clinic, but no further action was documented, leaving the resident to manage symptoms independently.
Two residents with cognitive and physical impairments experienced significant delays in receiving dental follow-up after their dentures went missing. The facility did not promptly initiate dental consultations or investigations, and staff were often unaware of the denture loss. Documentation showed gaps in communication and follow-up, resulting in prolonged periods without dentures and dissatisfaction with modified diets.
A resident with significant medical needs and a broken lower denture, who had consented to receive dental services, did not receive any dental care or evaluation during their stay. The facility's records showed no evidence of dental visits or attempts to arrange for denture replacement, and staff interviews confirmed a lack of awareness and action regarding the resident's dental needs.
A resident who had agreed to receive dental services did not receive them in a timely manner because their signed consent was not properly filed, resulting in staff being unaware of the request and the resident not being scheduled for dental care.
Failure to Coordinate and Document Timely Dental Services for a Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely provision and coordination of dental services for a resident who required dentures. The resident, admitted with multiple medical diagnoses including COPD, hemiplegia, CHF, major depressive disorder, anxiety disorder, dementia, hallucinations, and muscle weakness, reported via a concern form that his dentures were missing. The concern form documented that the dentures were later found broken and lodged in a toilet, and that the resident’s guardian was notified and indicated they would contact the dental company for the resident to be seen by a dentist. The resident’s care plan, dated shortly after this event, directed staff to monitor and notify the medical provider as needed for oral/dental problems and stated that the facility would coordinate arrangements for dental care and transportation as needed or ordered. Despite these care plan directives and the identified need for dental services, review of progress notes from early November through early January showed no documentation of any dental visits for the resident and no documentation of attempts to contact the guardian regarding dental care. In an interview, the Social Service Director confirmed that there were no documented guardian contact attempts in the medical record during this period and stated that the guardian was required to complete a dental consent form for the resident to receive dental care at the facility. The Social Service Director reported that the guardian was last contacted in mid-November and given information on the consent form but acknowledged that this contact was not documented and that there were no further contacts with the guardian through early January. The Social Service Director also stated they were unaware of any facility policy specifying how many times a guardian should be contacted to resolve resident issues.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to ensure timely dental services for a resident, as evidenced by the lack of documentation regarding a dental care plan or attempts to schedule a dental appointment for the resident since admission. The resident, who had diagnoses including type II diabetes mellitus with polyneuropathy and generalized anxiety, was observed to be without natural upper teeth and reported having lost several teeth during her stay. Despite expressing a desire to see a dentist, the resident had not been offered assistance in obtaining a dental appointment. Staff confirmed that the resident had lost teeth during her admission and that no dental appointments had been arranged. Medical record reviews also showed no issues with oral or dental status documented in the quarterly assessments, and no evidence of dental care planning was found.
Failure to Ensure Timely Dental Follow-Up for Broken Tooth
Penalty
Summary
A deficiency occurred when the facility failed to ensure a follow-up dental appointment was made for a resident who had a tooth broken off at the gum line. The resident, who had a history of stroke, coronary artery disease, heart failure, hypertension, and diabetes, was cognitively intact and independent in most activities of daily living except for transfers, for which a Hoyer lift was required. After an initial dental appointment where the dentist was unable to extract the root of the broken tooth, a referral for oral surgery was placed in the resident's chart. Subsequent documentation indicated the resident developed an infection at the site, was treated with antibiotics, and was to follow up with dentistry. Despite these events, the resident reported not having received any further information or scheduling for the necessary oral surgery to remove the root. The appointment scheduler stated that a message was left with the only surgical dental clinic accepting Medicaid, but the clinic's policy was to only return calls if an appointment could be scheduled. There was no evidence that further efforts were made to secure the required dental care, resulting in the resident continuing to experience issues with the broken tooth and self-managing symptoms with over-the-counter medication.
Plan Of Correction
F791 The facility failed to secure and follow up on an oral surgeon appointment for resident #29. Step 1: The facility ADON immediately assessed resident #29 with no negative effects noted. Completed on 6/13/25. Step 2: To identify other residents that have the potential to be affected, the DON or designee will audit resident medical records for residents seen by the facility dental provider (360 care) for any residents that might have had a referral for follow-up care with outside dental services. Completed on 6/27/25 with no negative findings. Resident #29 scheduled for oral surgeon consult at the Cleveland Dental Inst. 7/31/25 at 11am. Step 3: To prevent this from recurring, the facility DON will educate staff involved with resident appointments that if the facility scheduler or designee is unable to find dental services due to insurance being out of network for the resident, the facility will make arrangements to get the cost of dental services covered. Completed on 7/11/25. Step 4: To monitor and maintain ongoing compliance, the DON or designee will audit dental needs, including services and needed follow-up, weekly x4 weeks then monthly x2 months. Audits will begin 7/14/25. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.
Failure to Provide Timely Dental Services and Follow-Up for Missing Dentures
Penalty
Summary
The facility failed to ensure timely follow-up and provision of dental services for residents with missing dentures, affecting two of three residents reviewed for dental concerns. For one resident with a history of stroke, dementia, and malnutrition, the facility became aware of missing bottom dentures in August but did not initiate contact with a dental provider until October. The resident was placed on a mechanical soft diet due to the loss, which she disliked, and there were multiple delays and cancellations in scheduling dental appointments, including issues with payment authorization and communication with the dental office. The process to obtain replacement dentures was prolonged, with documentation showing significant gaps between identification of the issue and follow-up actions. Another resident with hemiplegia, diabetes, and vascular dementia also experienced a lack of timely follow-up after reporting missing dentures. Although prior authorization for denture adjustments was submitted, there was no documented follow-up or evidence that the resident received any denture adjustments for several months. The resident reported the dentures as stolen and expressed dissatisfaction with the modified diet. Staff interviews revealed a lack of awareness and inconsistent reporting regarding the missing dentures, and attempts to identify found dentures were unsuccessful due to missing identification labels. Facility policy required prompt investigation and follow-up within three days for lost or damaged dentures, as well as proper documentation and referral. However, the facility did not adhere to these requirements, resulting in extended periods without dentures for the affected residents and delays in dental care coordination. The deficiency was substantiated through observations, record reviews, and staff and resident interviews.
Failure to Provide Dental Services for Resident with Broken Denture
Penalty
Summary
A resident with a history of moderate protein-calorie malnutrition, stroke, adult failure to thrive, and legal blindness was admitted to the facility and was covered under Medicaid. Upon admission, the resident had an upper denture in fair condition and was noted to have lower dentures that were not brought to the facility due to being broken. The resident was cognitively intact, required assistance with oral hygiene, and had a care plan in place to address dental/oral status, including the need for dental evaluation and treatment as needed. The resident consented to receive dental services, as documented in the ancillary services consent form. Despite these documented needs and consent, there was no evidence in the medical record that the resident had been seen by a dentist since admission, nor were there any progress notes indicating attempts to arrange dental services to replace the broken lower denture. The contracted dental provider had visited the facility, but the resident was not seen during these visits. Interviews with staff confirmed a lack of awareness regarding the resident's denture status, and the DON confirmed that no dental services had been provided to the resident during their stay.
Failure to Provide Timely Dental Services Due to Misfiled Documentation
Penalty
Summary
A deficiency occurred when a resident who had agreed to receive dental services was not provided with those services in a timely manner. The resident, admitted with diagnoses including cerebral infarction, alcohol dependence, intellectual disabilities, and hypertension, had a care plan identifying the potential for oral health problems and interventions that included coordinating dental care. Documentation showed the resident was made aware of available ancillary services and had signed to receive dental care. However, the signed document was not properly filed in the resident's record. As a result, when the facility prepared for the dentist's visit, staff were unaware that the resident had elected to receive dental services. The resident reported not having seen a dentist since admission and had been requesting to do so. Staff interviews confirmed the oversight was due to the misfiled paperwork, which led to the resident not being scheduled for dental care as intended.
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