Failure to Refer Resident for Dental Services After Broken Tooth
Penalty
Summary
The facility failed to ensure that dental services were offered or provided to a resident who had a broken tooth. The resident's representative notified facility staff about the broken tooth, but there was no documentation or evidence that the resident was referred to dental services. Staff interviews confirmed that both nursing and social services staff were aware of the broken tooth but did not initiate a referral, with some staff stating that a referral was not made because the resident was not experiencing discomfort. The facility's policy required routine and emergency dental services to be available in accordance with the resident's assessment and plan of care, including referrals to community dentists or other dental providers. Observations showed the resident had difficulty chewing food, which was corroborated by the resident's own statements about the challenges of eating due to the broken tooth. Multiple staff members, including the Director of Nursing, acknowledged that a referral should have been made for the broken tooth, but no such referral or documentation was found. The lack of action resulted in the resident not receiving necessary dental care as required by facility policy.