Failure to Provide Routine Dental Care for Residents
Penalty
Summary
The facility failed to assist two residents in obtaining routine dental care, as required by regulations. Resident 4, who was admitted in February 2024, had several broken and missing teeth, but there was no documentation of routine prophylactic dental cleanings since admission. Despite a comprehensive dental assessment in October 2024, the facility did not provide evidence of any follow-up cleanings. Nursing documentation noted Resident 4's broken tooth in January 2025, but the facility did not act promptly to address his dental needs. Resident 3 had discolored, possibly broken, and missing teeth, and expressed the need for a tooth extraction. A dental note from July 2024 recommended the extraction of two non-restorable teeth, but there was no evidence of routine dental services being provided every six months as covered under the State plan. The facility's care plan for Resident 3, initiated in March 2020, included annual and as-needed dental referrals, but the facility failed to ensure these services were provided, as confirmed by the Director of Nursing.
Plan Of Correction
1. Resident 4: - The dentist was contacted for an evaluation of Resident 4's dental needs. The resident's dental care plan was updated to ensure routine six-month dental cleanings and ongoing monitoring for additional care needs. Resident 3: - A dental appointment was scheduled to reassess the condition of Resident 3's teeth and determine the need for extractions. Resident 3 was placed on a recurring schedule for prophylactic cleanings every six months, per State Plan coverage. 2. The Social Services Director (or designee) will conduct monthly audits to ensure all residents are receiving routine dental services and timely interventions for identified dental needs. The Facility will implement a designated staff member who will have and maintain a standardized process for tracking and following up on dentist recommendations with a Dental Services Log to track all resident dental visits, cleanings, and follow-ups. 3. The NHA will provide education to the DON and social service staff as well as a designated designee assigned to this with re-educated on routine and as-needed dental care, including: - Proper documentation of dental services provided. - Scheduling requirements for semi-annual cleanings and dentist referrals for issues such as broken teeth or cavities. - Timely follow-up on dentist recommendations and care plan updates. - Calendar record maintained for compliance tracking. 4. The DON or designee will conduct random chart audits weekly for four weeks to ensure all residents are receiving appropriate dental services and care. Audit results will be reviewed in QAPI meetings to determine ongoing monitoring.