Failure to Provide Dental Services Due to Incomplete Consent Process
Penalty
Summary
A deficiency was identified when a resident, admitted with diagnoses including morbid obesity and type II diabetes mellitus, was not provided with necessary dental services. Despite having intact cognition and no documented dental issues on the most recent MDS assessment, the resident reported ongoing dental pain, specifically in a left lower molar that appeared black and was deteriorating. The resident expressed a desire to see the dentist and indicated that pieces of the tooth were breaking off, with increased sensitivity and intermittent pain. Although the care plan included dental consults as needed and oral care interventions, there was no evidence that the resident had been seen by a dentist since admission. Review of the medical record revealed that a dental consult order was present, but the required consent form was left blank and not completed, preventing the resident from being scheduled for a dental visit. Interviews with staff, including a CNA, nurse, DON, and Medical Records Director, confirmed that the resident had not been seen by the dentist due to the missing consent. Staff were unaware of the resident's dental pain, and the process for obtaining and tracking dental consents was not effectively followed, resulting in the resident not receiving timely dental care.