Failure to Care Plan for Non-Compliance with Dental Assessments
Penalty
Summary
A deficiency occurred when the facility failed to develop and implement a comprehensive care plan addressing a resident's non-compliance with dental assessments. The resident, who was dependent on staff for all self-care and mobility needs and had significant medical conditions including a tracheostomy, ventilator dependence, and a gastrostomy tube, repeatedly refused or was unable to cooperate with dental staff during multiple visits. Dental consult notes documented the resident's inability to follow instructions and refusal to open his mouth, making dental assessments impossible. Despite these documented refusals and the resident's lack of decision-making capacity, the care plan did not include interventions or strategies to address the non-compliance with dental care. Interviews with facility leadership confirmed that refusals or non-compliance with care should be included in the care plan to alert staff and allow for appropriate interventions. The facility's own policy required comprehensive, person-centered care plans with measurable objectives and timetables, developed and revised as resident conditions changed, but this was not followed in the case of this resident.