Failure to Provide Dental Care After Resident Broke Tooth
Penalty
Summary
A resident with multiple diagnoses, including muscle weakness, protein calorie malnutrition, iron deficiency anemia, constipation, anxiety disorder, and dysphagia, was admitted to the facility and was moderately cognitively impaired. The resident was independent with eating and required set up assistance with oral hygiene. Medical record review and observation revealed that the resident had her own teeth and was noted to have cavities, but no broken teeth were documented during the oral cavity assessment. However, during an observation, it was found that the resident had a front left tooth that appeared to be broken in half, with the bottom half missing. The resident reported breaking her tooth while residing at the facility and stated she had not seen a dentist since the incident. Interviews with facility staff confirmed that the broken tooth was not previously identified or documented, and the resident had not been referred to or seen by a dentist after the tooth was broken. The facility's policy required nurses to contact the physician immediately upon any perceived change in condition and to refer to ancillary services as needed. Despite this, there was no evidence in the medical record or dental visit history that the resident received dental care or was referred for dental services following the incident.