Failure to Assist Resident in Obtaining Oral Surgery
Penalty
Summary
The facility failed to assist a resident in obtaining necessary oral surgery dental services, as required by federal regulations. The resident, identified as Resident #26, was observed to have missing top and bottom teeth and expressed a desire to see a dentist. Despite the facility's policy to assist residents in obtaining routine and emergency dental care, there was no dental care plan available for the resident, and the necessary arrangements for oral surgery were not made. The resident's records indicated a history of hypertension and other conditions, and the Minimum Data Service (MDS) assessment showed that the resident was mentally capable of making her needs known. The resident required substantial assistance for activities of daily living and setup assistance for eating. Despite these needs, the facility did not have a dental care plan in place, and the resident's dental consults recommended referral to an oral surgeon for tooth extraction, which was not followed through. Interviews with facility staff revealed a lack of coordination and follow-up regarding the resident's dental care needs. The Registered Nurse involved in the case confirmed that no further arrangements were made for the oral surgery, and the Director of Social Services acknowledged that the necessary arrangements were not completed. The facility's failure to assist the resident in obtaining the required dental services resulted in a deficiency in meeting the regulatory requirements for dental care in nursing facilities.
Plan Of Correction
Nursing or designee will monitor ongoing compliance through random audits. The corrective action accomplished for those residents affected include: Resident # 26 was reviewed and discussed with the residents dentist on was made on for a secondary dental for and resident # 26 was seen by the dentist on. Additional referral received on, and additional dental schedule at Nova Dental for. Other residents having the potential to be affected were identified by: An audit was conducted by the Director of Social Services on to identify if any other residents had missed their out-of-facility dental. No other residents were identified as missing dental services by the audit. The measures of systematic changes made include: The Social Service Department reviewed the policy and procedure on Dental Services on. Nursing Staff were reinserviced on, and regarding scheduling and follow-ups. The corrective actions put in place include: The Director of Social Services or designee will perform random audits on a monthly basis for dental visits, recommendations and compliance in follow-up and attendance. The Director of Nursing or designee will monitor ongoing compliance through random observations and chart reviews of nursing documentation and physician orders regarding dental updates. Findings will be reported to the QAPI Committee quarterly over the next six months with any necessary additional in-services.