Inaccurate Dental Status Assessment on Admission
Penalty
Summary
The facility failed to ensure that a resident's assessment accurately reflected her dental status. Record review showed that the resident, an elderly female with diagnoses including hypertensive heart disease, dementia, major depressive disorder, and legal blindness, was admitted on a specialized diet but had no care plan focus area addressing her dental status. The admission MDS assessment did not indicate that the resident was edentulous or had obvious dental issues, despite observations of sunken lips suggesting missing teeth. The quarterly MDS assessment also did not document dental concerns. During interviews, the Administrator confirmed the resident had some upper teeth but no lower teeth and sometimes did not use her dentures. The MDS LVN admitted to being confused when completing the MDS, as there was no problem with the resident's denture itself, and acknowledged that the assessment was coded incorrectly. The facility used the RAI manual as their policy for coding resident assessments.