Failure to Maintain Complete and Accessible Dental Records
Penalty
Summary
The facility failed to maintain a complete and readily accessible medical record for a resident who was reviewed for dental services. The resident, who had diagnoses including partial loss of teeth, anxiety, and obesity, was care planned to attend appointments without an escort and to receive education about appointment status. Despite the resident's report of a dental extraction performed by the facility's Consultant Dentist and subsequent complaints of pain and requests for dental records, the clinical record did not contain documentation of dental care and services provided by the consulting dental group for a significant period. The resident also reported that after the extraction, they began receiving dental care from a community dentist and had requested their dental records from the facility without follow-up. Upon surveyor inquiry, dental records from the Consultant Dentist were obtained and made accessible, revealing details of the extraction and subsequent dental complaints. Interviews with facility staff indicated a lack of awareness regarding the resident's request for dental records and confirmed that the dental records from the consulting provider were not immediately available in the resident's clinical record as required by facility policy. The facility's policy directs that all ancillary services, including dental, must be documented in the resident's medical record, specifying the type of service and outcome.