Failure to Provide Prompt Dental Care and Documentation
Penalty
Summary
The facility failed to provide prompt dental care and obtain post-visit dental documentation for one resident. The resident, who had a history of diabetes, depression, and muscle weakness, was observed to have broken and missing teeth and reported occasional oral pain. The resident had been referred by a Registered Dental Hygienist (RDH) for dental care on two separate occasions due to pain, but there was no documentation in the electronic health record (EHR) that the resident had been seen by a dentist or that a follow-up appointment was scheduled. The care plan indicated the need for dental care coordination, but this was not effectively carried out. Staff interviews revealed that the RDH's referrals were not properly communicated or documented, and the dental reports were not reviewed or signed by nursing staff as required. Although a dental appointment was scheduled and later confirmed to have occurred, the facility failed to obtain and include the dental visit documentation in the resident's EHR. The Social Services Director and Administrator both acknowledged that the expected documentation and follow-up were not present, and the dental summary report obtained later was unclear regarding the care provided. This lack of timely dental care and documentation did not meet facility expectations and requirements.