Failure to Assist Resident with Dental Appointment and Referral
Penalty
Summary
The facility failed to assist a resident with obtaining a dental appointment, despite clear indications of dental issues and a physician's order for a dental consult and treatment. Upon admission, the resident had multiple missing teeth, yellowish/gray teeth, and reported cavities, specifically noting a cavity in a molar and expressing an urgent need to see a dentist. The resident's Admission Record and Order Summary Report documented the need for dental care, and the Interdisciplinary Team Conference Summary noted the resident's request for a referral to a dentist. However, interviews and record reviews revealed that the Social Services Director (SSD) did not make the necessary dental referral or document any notification to dental services to ensure the resident would be seen. The SSD also had not met with the resident to discuss dental needs. Additionally, the social history assessment was incomplete, with no documentation under the dental section regarding the resident's dental condition or the need for a referral. The facility's policy required social services to make appropriate referrals and maintain documentation, but these steps were not followed in this case.