Delayed Dental Services Due to Lack of Follow-Up
Summary
The facility failed to ensure timely dental services for a resident, resulting in delayed dental care. The resident, who was admitted with multiple diagnoses including GERD, hemiplegia, and hemiparesis, was dependent on staff for personal hygiene and oral care. A dental exam conducted by a Doctor of Dental Medicine indicated the need for a deep cleaning by the facility's in-house hygienist. However, the Licensed Vocational Nurse was unaware of this referral until a later date, indicating a lack of communication and follow-up on the dental services required. The Social Services Director (SSD) acknowledged the delay in following up on the dental exam and referral, which was not acted upon until a family member requested a dental exam. The SSD admitted to not sending the referral for the hygienist immediately after the exam, as per facility policy. The facility's policies on dental and ancillary services require coordination and documentation of such services, which were not adhered to in this case, leading to the deficiency.
Penalty
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A resident with GERD, major depressive disorder, and protein calorie malnutrition, who was cognitively intact and independent with oral hygiene, developed tooth pain and a dental abscess that was treated only with antibiotics. Facility assessments documented tooth pain and abscessed teeth, but the care plan did not address broken or decayed teeth or specify dental services. Observation later revealed the resident had missing teeth, one decayed and split tooth, and another broken at the lower jaw. An administrative nurse acknowledged she had not assessed the resident’s mouth until the survey, confirmed the presence of two broken teeth, and verified the resident was not enrolled in the facility’s dental services and had received no dental care since admission, contrary to the facility’s routine dental care policy.
A resident with heart failure, stroke, and diabetes had a lump on the gums reported by family, who provided a photo to the social worker. The social worker notified the care team and contacted the dental vendor, and later believed the dentist had evaluated the resident and determined the lump was an extra piece of bone not requiring surgery, while the family felt it impaired chewing and denture use. Documentation produced on request showed that the resident was not actually seen by the dentist, was not on the dentist’s final list, and that only a discussion with the family about a mandibular torus occurred; the form was unsigned and largely blank. The NHA confirmed the dentist never assessed the resident’s mouth, and the dental visit was not entered into the EHR, contrary to the facility’s dental services policy.
A resident with multiple complex diagnoses, including quadriplegia and severe protein calorie malnutrition, reported chewing only on one side due to painful teeth with holes on the opposite side, yet had not been seen by dental services at any time during her stay. The DON stated that residents are supposed to receive dental screenings on admission, quarterly, and as needed, but this process was not carried out for this resident. This was inconsistent with the facility’s dental services policy, which requires licensed nurses to perform comprehensive oral assessments, inquire about chewing difficulties and pain, inspect the oral cavity, and promptly address any negative findings through physician and dental provider notification.
A resident with intact cognition and poor dentition, including broken, decayed, and missing teeth, was care planned to receive assistance with oral care and dental appointments as needed, but assessments failed to document dental problems or pain. After an initial dental visit identified extensive caries and recommended fillings and extractions by an oral surgeon, and a later hygienist exam noted ongoing mouth pain and inflammation requiring further dental evaluation, no documented follow-up dental appointment or rationale for lack of follow-up was found in the medical record. The resident reported tooth pain and difficulty eating, and staff confirmed the absence of documentation despite a facility policy requiring timely dental referrals, documentation of refusals, and recording of interventions while awaiting dental services.
A resident with dementia, dysphagia, and severe cognitive impairment lost a lower denture and subsequently relied on a poorly fitting, painful temporary denture brought from home, which she often refused to wear. A grievance was filed by the family, and the Social Worker obtained consent paperwork and scheduled an in-house dental appointment for denture replacement several months later, without attempting to secure an earlier visit or contact an outside dentist, despite the resident’s swallowing difficulties and high choking risk identified by a FEES study. The resident’s care plan noted oral/dental problems and the need to coordinate dental care, and observations showed her eating soft bite-size foods without the lower denture, chewing slowly and with food smeared on her clothing, while staff and therapy providers acknowledged that having a full set of dentures was important for her eating and swallowing.
A resident with multiple chronic conditions and intact cognition reported that dentures documented on an earlier inventory were missing after readmission, but staff did not complete a grievance form or provide timely follow-up as required by facility policy. The resident repeatedly requested to speak with administration and Social Services without receiving a response, and although the resident was placed on a monthly dental sign-up list, the resident was never actually seen by the dental provider before discharge. Facility policies required grievances to be filed and addressed within 72 hours and mandated prompt dental referral within three days for lost dentures or documentation of measures taken to ensure the resident could still eat and drink, but these procedures were not followed for this resident.
Failure to Facilitate Necessary Dental Services for a Resident with Abscessed and Broken Teeth
Penalty
Summary
The facility failed to provide necessary routine and 24-hour emergency dental care for a resident who required dental services. The resident’s EMR documented diagnoses of GERD, major depressive disorder, and protein calorie malnutrition, with an admission MDS showing intact cognition and independence with oral hygiene. Initial assessments recorded that the resident did not have natural teeth or dentures and had recent weight loss, but lacked further dental documentation. A Dental Care CAA later recorded tooth pain on the right side and initiation of an antibiotic for a dental abscess. Nursing notes documented the resident’s report of a tooth abscess, mouth soreness, and pain, followed by an order for Clindamycin 300 mg four times daily for seven days and continued antibiotic treatment for abscessed teeth. Despite these documented dental issues and the facility’s Routine Dental Care policy requiring ongoing assessments, physician notification, and dental consultation as appropriate, the resident’s care plan contained no reference to broken or decayed teeth or to dental services to be provided. Observations showed the resident eating with missing teeth, one decayed and split tooth, and another broken off at the lower jaw. The Administrative Nurse confirmed she had not visualized the resident’s mouth or teeth until the survey date, verified the resident was edentulous except for two broken teeth, and acknowledged the resident was not on the facility’s dental services and had not received any dental care or services since admission, despite the facility’s policy outlining initial evaluation of dental needs, consultation with a dental consultant, and a daily oral hygiene plan of care.
Failure to Ensure Dental Assessment for Resident With Oral Lump
Penalty
Summary
The facility failed to ensure that a resident received an appropriate dental assessment in accordance with its Dental Services Policy, which states that the facility will assist residents in obtaining routine and 24-hour emergency dental care and that all dental services will be recorded or scanned into the medical record. The resident, identified as R14, was admitted to the facility and had documented diagnoses including heart failure, stroke, and diabetes. A progress note indicated that the social worker spoke with the resident’s family, who showed a picture of a lump on the resident’s gum. The social worker discussed this concern with the care team and contacted the dental vendor to schedule a dentist visit. The social worker later reported that the resident had been seen by the dentist and that the dentist considered the lump to be an extra piece of bone not requiring surgical intervention, while the family believed the lump affected the resident’s ability to chew and wear dentures. When the surveyor requested the dental exam, the facility produced a form not scanned into the electronic health record, which documented a date of service but stated that the resident was not seen and was not on the dentist’s final list. The form indicated that the dentist only spoke with the family about a mandibular torus and that the resident would need an oral surgeon for removal, but it was not signed by the dentist and was left otherwise blank. The Nursing Home Administrator confirmed that the dentist never actually saw or assessed the resident’s mouth, demonstrating that the resident did not receive the dental assessment required by facility policy and state nursing services regulations.
Failure to Provide Routine Dental Services and Oral Assessment
Penalty
Summary
The facility failed to provide routine dental services as required, affecting one resident who reported ongoing dental pain and functional impairment. During an interview, the resident stated she could only chew on the left side of her mouth because the upper and lower teeth on the right side had holes and became painful when food became stuck. Observation, interview, and record review confirmed that this resident had not received dental services during her stay, despite her reported symptoms. The DON stated that residents are to be screened upon admission, quarterly, and as needed for dental concerns, but acknowledged that this resident had not been seen by dental services at any time during her residency. The resident, who is diagnosed in part with quadriplegia, unspecified severe protein calorie malnutrition, neuromuscular dysfunction of the bladder, asthma, myasis, myopathy, and essential hypertension, was therefore not assessed and referred for dental care in accordance with the facility’s own dental services policy. That policy requires licensed nurses to conduct comprehensive oral assessments, including asking about chewing difficulties and pain, physically inspecting the oral cavity, and immediately addressing negative findings by notifying the physician and dental provider, which did not occur for this resident.
Failure to Provide Timely Dental Follow-Up and Pain Management
Penalty
Summary
The deficiency involves the facility’s failure to provide timely dental care and follow-up for a resident with documented dental problems and pain. The resident’s MDS showed intact cognition and a need for staff assistance with personal and oral hygiene, with no oral or dental issues identified on that assessment. The ADL Care Plan documented that the resident had his own teeth in poor condition, with caries and missing teeth, and required setup to partial assistance with oral care, with dental appointments to be arranged as scheduled, needed, or requested. A CAA for ADLs did not identify or document any signs or symptoms of dental problems or pain despite the resident’s broken, decayed, and missing teeth. Interdisciplinary notes documented that the resident was seen by a dentist for a lost tooth and mouth pain, with findings of extensive gross caries and recommendations for staff to brush the resident’s teeth and for the resident to return for fillings and extractions, with extractions to be done by an oral surgeon. Later, a dental hygienist’s exam at the facility documented pain in the upper mouth, moderate inflammation, and the need for further evaluation by a dentist. The resident reported broken and missing teeth, pain in the upper jaw, and difficulty eating due to tooth pain, and observation confirmed missing, decayed, and broken teeth. The Administrative Nurse verified the prior dental appointment and recommendations but could not find any documentation of a follow-up appointment or reasons why it was not made, and confirmed there was no documentation in the medical record, despite the facility’s dental services policy requiring timely referral, documentation of refusals, and documentation of interventions while awaiting dental services.
Failure to Timely Arrange Dental Services for Replacement of Missing Denture in Resident With Dysphagia
Penalty
Summary
The deficiency involves the facility’s failure to arrange necessary dental services to replace a missing lower denture for a resident with dysphagia and dementia. The resident was admitted with diagnoses including dysphagia and dementia and had a physician’s order for a modified texture diet of soft bite-size food with mildly thick liquids. A quarterly MDS assessment documented severe cognitive impairment, moderately impaired vision, and a need for setup or cleanup assistance with eating and oral hygiene. At the time of that assessment, the resident had no documented dental issues and was receiving a mechanical and therapeutic diet. A grievance was filed by the resident’s Responsible Party (RP) reporting that the resident’s lower denture was missing. The Social Worker documented that the family brought in an extra pair of dentures and that paperwork was being completed so the resident could receive in-house dental care, with the grievance resolution stating that in-house dental would come at the beginning of the year as the earliest time to start replacing dentures. The Social Worker reported she did not receive the completed paperwork back until several weeks later, at which time she scheduled an in-house dental appointment for denture replacement, with the earliest available date several months away. She did not attempt to obtain an earlier appointment or contact an outside dentist, despite the resident’s dysphagia diagnosis. The RP reported that the temporary lower denture brought from home did not fit well, caused the resident pain, and that the resident did not like to wear it. Staff interviews confirmed that the resident had a lower denture in the room that she did not like to wear because it caused pain, and that she could indicate pain by grimacing or saying no. A care plan revision documented oral and dental health problems with risk for further decline and decline in nutritional intake related to wearing dentures, with an intervention to coordinate dental care as needed. Observation showed the resident eating soft bite-size foods without the lower denture, chewing slowly and with food smeared on a towel. Therapy staff and the Speech Therapist noted the resident’s high risk of choking and the importance of a full set of dentures, and the DON later acknowledged awareness of the missing denture but not of the long delay in scheduling replacement, and stated that an outside dentist should have been used if the in-house appointment was six months away.
Failure to Process Grievance and Arrange Timely Dental Services for Missing Dentures
Penalty
Summary
The deficiency involves the facility’s failure to timely address a resident grievance regarding missing dentures and to ensure provision of dental services as outlined in facility policy. The resident, an adult with diagnoses including lipoprotein deficiency, plasma-protein metabolism disorder, glaucoma, legal blindness, right ear hearing loss, essential hypertension, low BMI, and right foot pain, was cognitively intact with a Brief Interview for Mental Status score of 14. An inventory list dated prior to hospitalization documented upper and lower dentures, while a subsequent inventory list after readmission showed no dentures. Upon readmission, the resident reported the dentures missing, but no grievance form was completed by the staff who received the concern, despite facility policy requiring grievances/concerns to be filed and followed up within 72 hours. The resident reported repeatedly asking to speak with the Administrator, being told the Administrator was on vacation, being redirected to the Assistant Administrator without follow-up, and speaking with Social Services without receiving any response regarding the missing dentures. The facility also failed to ensure timely referral and provision of dental services after the dentures were reported missing. Facility policy required that if dentures are lost or damaged, the resident must be promptly referred for dental services within three days, or the facility must document what was done to ensure the resident could still eat and drink and any extenuating circumstances for delay. Staff interviews confirmed that the Social Services staff reported the missing dentures to administration but did not complete a grievance form, and the Assistant Administrator acknowledged awareness of the concern without initiating the grievance process. The DON stated that residents who report missing dentures are to be referred to dental services, but was unsure why this resident was not seen by dental services before discharge. Although the Activity Director indicated the resident was placed on a monthly sign-up list for dental services, the resident was not actually seen by the dental provider prior to discharge, and the resident reported not seeing any dental services or being informed of any follow-up on the dentures during the stay or after discharge.
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