Failure to Timely Address and Document Dental Complaint
Penalty
Summary
The facility failed to promptly provide dental services for a resident who was admitted with diagnoses including dysphagia, GERD, and anxiety disorder. The resident had moderate cognitive impairment but was able to make decisions and communicate needs. A family member verbally reported the resident was experiencing a toothache to the Social Services Director (SSD), but the SSD did not document the chief complaint or ensure a timely and specific referral to the dentist. When the resident was eventually seen by the dentist, the dental record did not indicate the reason for the referral or the resident's chief complaint. The dentist documented no pain, no swelling, and no visible pathology, but there was no evidence that the toothache complaint was addressed. The SSD acknowledged that the dental referral log and dental records lacked documentation of the chief complaint, and she was unsure if the resident was evaluated for the reported toothache. Additionally, the SSD did not follow up with the family member to confirm whether the dental issue had been resolved. Interviews with other staff, including the Director of Staff Development and Assistant Director of Nursing, confirmed that the process for referring and following up on dental complaints was not followed as required by facility policy. The lack of documentation and follow-up had the potential to result in unresolved pain and discomfort for the resident.