Failure to Follow Up on Dental Recommendations and Document Care
Penalty
Summary
The facility failed to follow up with dental recommendations for a resident who was cognitively intact and had multiple diagnoses, including anxiety, depression, atrial fibrillation, hypertension, and heart failure. The resident reported that a problematic tooth needed extraction, and although she had seen a dentist about a year prior, the extraction was never completed. The care plan indicated the need for coordination of dental care, and dental notes documented recommendations for follow-up exams, cleanings, and extractions. However, there was no evidence in the clinical record that these follow-up dental services were provided within the recommended timeframes. Further review revealed that after an outside dental provider recommended extraction of three teeth, with the resident consenting to the removal of only the broken tooth, no follow-up was documented. The dental provider reported not receiving the necessary medical clearance from the resident's physician, despite multiple attempts, and the facility did not contact the provider after the appointment. Interviews with staff showed a lack of documentation and follow-through on dental recommendations, and conflicting accounts from the resident and staff regarding her consent for the procedure. The facility's policy required assistance with dental appointments and documentation of all actions, which was not followed in this case.