Failure to Follow Up on Dental Referral for Resident with Ongoing Jaw Pain
Penalty
Summary
The facility failed to ensure timely follow-up on a dental referral for a resident who had ongoing lower jaw pain. According to the facility's policy, residents are to be assisted in obtaining routine and emergency dental services, with referrals for dental procedures to be made within three days and documented if delayed. In this case, a resident with a history of bipolar disorder, left hemiplegia, major depressive disorder, and PTSD reported persistent pain in her lower jaw and had previously been seen by the facility dentist, who recommended an alveoloplasty. However, there was no documentation in the resident's medical record that the referral for this procedure, recommended in November, had been made or followed up on. The resident stated she had been waiting for months for a dental appointment and had not received any communication from the facility regarding the status of her referral, despite ongoing discomfort. Staff interviews confirmed that the social services department was responsible for coordinating dental care, but the facility was in the process of hiring new social services staff at the time. The nursing home administrator was unable to find any documentation that the dental referral had been initiated or completed for the resident as recommended by the dentist.