Failure to Develop Comprehensive Dental Care Plan
Penalty
Summary
A deficiency was identified when the facility failed to develop a comprehensive and resident-centered dental care plan for a resident who was admitted with multiple diagnoses, including encephalopathy, compression fractures, bipolar disorder, panic disorder, and malnutrition. The resident's admission record and Minimum Data Set (MDS) indicated that the resident was able to participate in assessments and goal setting, could be understood, and required substantial to maximal assistance with activities of daily living. The Social Services Evaluation noted the presence of missing teeth and indicated that a referral to dental consultation would be made as needed. However, upon review, it was found that no care plan addressing oral or dental health was created for the resident at the time of admission. Interviews with facility staff, including a Registered Nurse Supervisor, Social Services Director, and Director of Nursing, confirmed that the dental issue should have been included in the resident's care plan. Staff acknowledged the importance of initiating a care plan to set goals and provide proper care and treatment, as well as to facilitate communication between departments. The facility's policy requires that a comprehensive care plan, including measurable objectives and timetables, be developed for each resident within seven days of completing the comprehensive assessment, but this was not done for the resident's dental needs.