Failure to Provide Routine Dental Services for Resident with Severe Cognitive Impairment
Penalty
Summary
The facility failed to provide routine dental services to one resident with severe cognitive impairment and a history of acute cerebral vascular insufficiency and dysphagia. The resident was observed to be edentulous and unable to communicate about his oral health needs. Despite a physician order for a dental evaluation and treatment, there was no documentation in the care plan addressing dental concerns or the absence of teeth. The Minimum Data Set (MDS) for the resident did not have the oral/dental status completed. Interviews with facility staff revealed that the social worker was unaware of the resident's dental needs, even though a physician order was present. The DON acknowledged that the resident should have been seen by a dentist and confirmed that the social work department was responsible for arranging dental appointments. Dental notes for the resident were requested but not provided by the time of survey exit. Facility policy indicated that referrals to ancillary providers should be made based on identified needs, but this process was not followed for the resident in question.