Failure to Follow Up on Dental Referral for Resident with Oral Lesion
Penalty
Summary
The facility failed to follow up on a physician's recommendation for dental care for a resident with multiple diagnoses, including pulmonary embolism, dementia with behavioral disturbance, schizophrenia, anxiety disorder, and depression. The physician's order called for dental care as needed, and during a dental vendor visit, a lump or lesion was identified on the resident's lower right lip. The dentist recommended that the lesion be evaluated by an oral surgeon, but there was no evidence that this consultation was arranged or followed up on by the facility. The resident was observed verbalizing tooth pain while sitting in a wheelchair, and a staff member communicated this concern to the nurse. Interviews with nursing staff revealed that the last documented dental visit in the resident's chart was from the previous year, and the Director of Nursing Services confirmed that no oral surgeon consultation had been set up for the lesion. The facility's dental services policy requires providing both routine and emergency dental services, including outside resources as needed, but this was not done in this case.