Inaccurate MDS Assessment of Oral/Dental Status
Penalty
Summary
The facility failed to ensure that a resident's comprehensive Minimum Data Set (MDS) assessment accurately reflected her oral and dental status. Specifically, the MDS indicated that the resident had no natural teeth, dentures, oral abnormalities, pain, or inability to examine the oral cavity, when in fact, the resident had no natural teeth and used full top and bottom dentures. This discrepancy was identified through record review, interviews, and direct observation, which revealed the presence of denture care items in the resident's bathroom and the resident's own statements about her dentures. Further investigation showed that the resident had a history of living without natural teeth for years and was admitted to the facility with dentures. Dental records confirmed ongoing denture care, including inspection and cleaning, and noted a broken tooth on the top denture. Interviews with staff indicated that while some were aware of the resident's use of dentures, others were unsure, and documentation practices varied. The resident herself reported not wearing her dentures due to the broken tooth and awaiting dental repair, but she continued to take pride in her appearance and managed the storage of her dentures independently. The MDS Coordinator acknowledged that the assessment should have indicated the absence of natural teeth and the presence of dentures. Facility policy required that MDS assessments be completed accurately by qualified staff familiar with the resident's status, using direct observation and communication with both the resident and care staff. The failure to accurately document the resident's dental status on the MDS was contrary to both facility policy and federal regulatory requirements.