Failure to Follow Up on Dental Referral and Oral Care Recommendations
Penalty
Summary
The facility failed to ensure that a routine dental referral and recommended oral care interventions were followed for a resident who was cognitively intact and required supervision with oral hygiene. The resident had a history of broken natural teeth, inflamed and bleeding gums, and was self-conscious about a missing front tooth. A dental assessment recommended direct staff supervision for oral care, use of an over-the-counter fluoride rinse twice daily, and a dental referral to repair or replace the missing tooth. However, the resident's care plan did not include interventions for the fluoride rinse, and there were no active orders or documentation indicating the resident was using the rinse or that the dental referral was followed up on. Interviews with facility staff revealed a lack of awareness and follow-through regarding the dental recommendations. The social services designee was unaware if the resident had been scheduled for a follow-up dental appointment, and the Health Information Director (HID) confirmed that the referral for dental repair was not acted upon. The HID also stated that he was responsible for reviewing dental forms and following up on recommendations but had not done so in this case. The registered nurse was similarly unaware of the recommendations for the fluoride rinse and dental follow-up. Facility policy required assistance in obtaining routine dental care, but this was not provided as required for the resident.