Failure to Provide or Facilitate Dental Services for Resident with Dental Decay
Penalty
Summary
The facility failed to provide or facilitate access to dental services for a resident with widespread dental decay. The resident had a history of major depressive disorder, cerebrovascular accident, and was dependent on staff for several activities of daily living, including requiring set-up assistance for oral care. Despite care plan documentation indicating oral and dental health problems and directing staff to coordinate dental care, there was no evidence in the electronic health record that dental services were offered or facilitated, nor that the resident had declined such services. The resident reported that no staff had asked about dental assessment since admission and described having several broken teeth, which was confirmed by observation. Interviews with facility staff revealed that the process for arranging dental appointments involved documentation in the EHR or verbal communication with social services, but there was no record of this occurring for the resident in question. The social services designee stated that residents must sign a consent or declination for dental services, but no such documentation could be found for this resident. The facility's policy required an initial dental evaluation upon admission, but this was not completed for the resident, resulting in a lack of dental care despite clear need.