Failure to Accurately Assess and Document Resident's Dental Status
Penalty
Summary
The facility failed to accurately assess and document the dental status of a resident during the Minimum Data Set (MDS) assessment process. Observations and interviews revealed that the resident had no upper teeth and only three lower teeth, yet the admission MDS assessment did not indicate that the resident was edentulous or had any tooth fragments. Additionally, the resident's current care plan did not include information regarding their dental status. The resident also reported not having dentures, and direct observation confirmed the absence of upper teeth and the presence of only three lower teeth. The resident's clinical record showed diagnoses including malignant neoplasm of the stomach, gastric ulcer, unspecified cirrhosis of the liver, and major depressive disorder. The MDS assessment noted moderate cognitive impairment and a need for partial to moderate assistance with eating. Despite these findings and the resident's self-reported dental condition, the facility did not accurately document or assess the resident's oral health status as required by the Resident Assessment Instrument (RAI) guidelines.