Failure to Provide Annual Dental Care
Penalty
Summary
The facility failed to provide mandatory annual dental care and services for a resident, identified as Resident #15. The deficiency was observed when the surveyor noted the resident's teeth were brown, discolored, chipped, and some were missing. The resident was admitted with a diagnosis of Type 2 diabetes mellitus and had a moderately impaired cognition with a BIMS score of 10 out of 15. Despite the resident's oral health issues being noted in the Nursing Comprehensive Assessment, the comprehensive Minimum Data Set (cMDS) inaccurately reflected the resident's oral condition, indicating no issues with dentures or natural teeth. Furthermore, there was no order for a dental consultation in the resident's Order Summary Report, and the electronic medical record (eMAR) lacked documentation of offered or refused dental care services. The facility's Care Plan for the resident included interventions for oral/dental health problems related to poor hygiene, yet there was no evidence of dental visits for the resident in the records provided by the Director of Nursing. Interviews with the Licensed Practical Nurse Unit Manager and the Director of Nursing revealed that the facility's policy required a physician order for dental consults based on admission assessments, which was not followed in this case. The facility's Dental Services Policy and Agreement were in place, but the resident's dental needs were not addressed as required, leading to the identified deficiency.
Plan Of Correction
1. Residents affected by deficient practice The facility failed to provide the annual [R] and services to Resident #15. On 12/5/24, Resident #15 was requested to be seen by [R] during next scheduled visit. 2. Identifying other residents who could be affected by the deficient practice: All residents have the potential to be affected by this deficient practice. 3. Measures or systemic changes to ensure that the deficiencies will not recur: The Dental Services Policy was reviewed with the Unit Managers, Unit Secretary and Director of Social Services by the Assistant Director of Nursing. Audit conducted for long-term residents to ensure they received a dental consult. 4. Monitoring the continued effectiveness of the systemic change: The Social Worker will complete an audit of five residents to ensure they have been seen by the Dentist. This audit will be completed Monthly x 3 months. Results of the audit will be reviewed at the Monthly Quality Assurance Meeting and Quarterly over the duration of the audit process to ensure compliance and reassessed for further action.