Failure to Inform Resident of Dental Treatment Recommendation
Penalty
Summary
The facility failed to inform a resident with a history of epilepsy, hypertension, and congestive heart failure about a dental treatment recommendation for tooth extraction. The resident was cognitively intact and able to make decisions, as documented in both the History and Physical and the Minimum Data Set. Dental notes indicated that the resident was evaluated for molar pain and a tooth extraction was recommended. However, there was no documentation in the Interdisciplinary Team notes that the resident was notified of this recommendation. During interviews, the resident confirmed being seen by the dentist for tooth pain but stated that no staff had communicated the dentist's plan. The Social Service Director acknowledged awareness of the dental recommendation and admitted to not documenting any notification to the resident, stating that if it was not documented, it was not done. The Director of Nursing also confirmed that residents have the right to be involved in their care planning and that such changes should be discussed in care conferences. The facility's policy supports the resident's right to be informed and participate in care planning, but this was not followed in this instance.