Failure to Arrange Dental Referral as Ordered
Penalty
Summary
The facility failed to ensure a referral was made to an oral surgeon as ordered for a resident who required dental services. The resident, who was moderately cognitively impaired and had a history of a bacterial infection and a broken tooth, had a physician's order dated 03/31/2025 for appointments with an oral surgeon and endodontist for a tooth extraction and root canal. The care plan included coordinating dental care and transportation as needed. Nurse's notes and a nurse practitioner note confirmed the need for referral following a dental abscess and antibiotic treatment. Despite these orders and documentation, the staff member responsible for scheduling appointments was not aware of the referral order, as she had not received the printed order report from the DON. As a result, the appointment for the necessary dental procedures was not made. Interviews with the staff confirmed the breakdown in communication and process, with the DON acknowledging that the order report should have been provided to the scheduler to ensure the referral was completed.