Failure to Provide Annual Dental Services for Resident
Penalty
Summary
The facility failed to provide up-to-date annual dental services for a resident with significant medical conditions, including altered mental status, dementia, muscle weakness, dysphagia, and visual impairment. The resident was admitted in 2018 and had a care plan that included an annual dental consult. During the survey, the resident was observed to have swollen gums and no teeth on the bottom row, and reported pain while eating. The Minimum Data Set (MDS) and electronic health record (EHR) lacked current documentation in the oral/dental status section, and there was no evidence of a recent dental exam. Interviews with the social worker revealed that dental records for the resident could not be located, and the last documented dental exam was from 2022, despite the facility's policy requiring annual dental services. The social worker indicated a misunderstanding regarding the need for dental exams for edentulous residents and was unable to confirm when the last annual dental exam occurred. The facility's policy stated that routine and emergency dental services should be available and that social services would assist with appointments, but these procedures were not followed for this resident.