Failure to Provide Routine and Emergency Dental Care
Penalty
Summary
A resident with a history of dysphagia and essential hypertension, who was totally dependent on staff for activities of daily living and had moderately impaired cognitive skills, was observed to have multiple broken, missing, and discolored teeth. The resident reported not having seen a dentist in several months, although she denied being in pain at the time of the interview. Review of the medical record revealed a physician's order allowing for dental consult and treatment as needed, but there were no dental records or progress notes indicating that the resident had received any dental care since admission. Interviews with facility staff, including the Social Service Director and the Director of Nursing, confirmed that the resident was supposed to receive dental services every 6 to 12 months and as needed, in accordance with facility policy. The lack of documented dental care and absence of dental records for the resident since admission constituted a failure to provide routine and emergency dental services as required by both physician orders and facility policy.