Failure to Assess and Provide Dental Services for Edentulous Resident
Penalty
Summary
The facility failed to provide or obtain appropriate dental services for a resident with diagnoses including epilepsy, left-sided hemiplegia, and chronic obstructive pulmonary disease. Upon admission, the nursing clinical assessment did not include an examination of the resident's oral or dental status, and the assessment inaccurately documented that the resident had all natural teeth. The resident's care plan did not address the edentulous status, and the Minimum Data Set (MDS) assessments, both at admission and subsequently, failed to identify that the resident was without teeth. The clinical record did not show that the resident had been seen by a dentist, despite the resident expressing a desire for dentures and reporting that previous dentures had been discarded prior to admission. Observations and interviews confirmed the resident was edentulous and had not received dental services or been offered a dental consultation. Nursing staff, including the RN responsible for the admission assessment, were unaware of the resident's true dental status and acknowledged inaccuracies in the documentation. The Director of Nursing Services and other staff confirmed that oral assessments should have been completed at admission and before each MDS, and that edentulous residents should receive dental consultations, but could not explain why these steps were missed. Facility policy required physical assessment of teeth and gums and timely referral for dental services if dentures were lost, but these procedures were not followed for this resident.