Inaccurate Dental Assessment Documented in MDS
Penalty
Summary
The facility failed to complete an accurate comprehensive dental and oral assessment for a resident. Upon admission, the resident was documented as alert and oriented. The Medicare 5-day Minimum Data Set (MDS) assessment indicated that the resident did not have broken or loose natural teeth. However, during an observation, the resident was seen with broken and loose teeth, and was able to move his front teeth with his tongue. A subsequent assessment by an LPN confirmed the presence of loose and broken teeth. The Infection Preventionist/Registered Nurse later reviewed the MDS assessment and acknowledged that it was incorrect, as the resident did have broken teeth. The expectation was that an accurate physical assessment would be completed and documented in the MDS assessment.