Failure to Maintain Accurate Dental Appointment Records
Penalty
Summary
The facility failed to maintain accurate and complete medical records regarding dental appointments for a resident with multiple diagnoses, including hemiplegia/hemiparesis, cerebral atherosclerosis, atrial fibrillation, and anemia. The resident was cognitively intact and required set-up assistance for oral and personal hygiene. Documentation showed that the resident was scheduled for several dental appointments, both onsite and offsite, as indicated by transportation lists and ancillary service calendars. However, progress notes from the dental service repeatedly stated that the resident was not seen because they did not present to the clinic or were not brought to the clinic. Despite these missed appointments, the facility was unable to provide documentation in the resident's medical record explaining the reasons for the resident's absence from the dental clinic or any evidence that the appointments were rescheduled. Interviews with the Social Service Director and the Administrator confirmed that such documentation should have been present in the medical record but was not. This lack of documentation is inconsistent with the facility's policy, which requires all dental services provided to be recorded in the resident's medical record.