Failure to Assess and Monitor Dental Care Needs
Penalty
Summary
The facility failed to adequately assess, monitor, and provide care for a resident with significant dental needs. The resident, who has Alzheimer's disease, dementia, abnormal posture, and is nonverbal with limited movement, was observed exhibiting behaviors such as clenching her shirt and teeth, which her husband identified as signs of pain. Despite a dental consultation indicating the need for diagnostics and oral surgery for a tooth extraction under sedation, there was no documented follow-up by the facility after the initial referral. Nursing progress notes indicated a dental appointment occurred, but no procedures were performed, and there was no evidence of further follow-up or communication with the physician regarding ongoing dental concerns. The resident's care plan did not address dental issues, and pain assessments consistently recorded a pain level of 0/10, despite ongoing reports of pain-related behaviors. Staff interviews revealed uncertainty about monitoring for pain and infection, especially given the resident's inability to express discomfort verbally. There was also a lack of documentation regarding monitoring for infection or updating the physician about the resident's dental needs. The facility did not have a system in place to ensure ongoing assessment and intervention for the resident's dental pain and potential infection, as required by professional standards of practice and the resident's care plan.
Plan Of Correction
F684 1. Resident #30 still currently resides in the facility; Ultram has been ordered for her pain and she is being monitored daily for any s/sx of dental infections. Her plan of care has been updated to reflect her status. Resident #30 is scheduled for tooth extraction. 2. Like residents are identified as those requiring dental services outside the facility. The plans of care for all like residents were reviewed by 4/30/2025 and updated to reflect the residents' current needs and treatment. Follow-up appointments and responsible party notification were documented by 4/23/2025. 3. Policy on Ancillary Services has been reviewed and revised. Social worker was educated by the DON/designee by 4/23/2025 on appropriate process. Licensed nurses were educated on identification, notification, and treatment of dental pain. 4. The QAPI committee has directed the DON/designee to perform random weekly audits of all residents currently in the facility receiving offsite dental services to ensure they are being monitored for their dental issues and their plan of care addresses their needs. The Administrator is responsible for ensuring that substantial compliance is attained through the Plan of Correction and is maintained thereafter. The results will be provided to the QAPI Committee for further follow-up and review.