Inaccurate Oral/Dental Status Documentation in Resident Assessments
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the oral and dental status of three residents. Specifically, the Minimum Data Set (MDS) assessments for these residents did not correctly document the presence or absence of natural teeth, despite evidence from care plans, dental records, and resident interviews indicating otherwise. For example, one resident was coded in the MDS as having all natural teeth intact, while her care plan and interview confirmed she had dentures and did not use her lower set due to poor fit. Another resident was also coded as having no oral/dental problems, but dental records and interviews confirmed she was edentulous and had requested new dentures due to discomfort from chewing without teeth. A third resident's MDS assessment indicated the presence of obvious or likely cavities or broken natural teeth, but during an interview, the resident stated he had no teeth and used both upper and lower dentures, which fit properly. The discrepancies between the MDS documentation and the actual oral status of the residents were identified through observation, interviews, and review of care plans and dental records. These inaccuracies in the MDS assessments were not aligned with the residents' current conditions as observed and reported. The MDS Coordinator acknowledged responsibility for ensuring the accuracy of MDS assessments and stated that assessments were completed by visiting residents, talking to them, and reviewing nursing documentation. However, the inaccuracies persisted, and the facility's policy was to follow the RAI manual for assessment accuracy. The failure to accurately assess and document the residents' oral and dental status could impact the care and services provided to them.