Failure to Obtain Ordered Oral Surgery for Resident
Penalty
Summary
A deficiency occurred when the facility failed to obtain and follow through with ordered dental services for a resident who required surgical extraction of two severely decayed molars. The resident, who had multiple medical diagnoses including diabetes, morbid obesity, heart disease, seborrheic dermatitis, and schizoaffective disorder, was seen by a dentist at bedside for tooth pain. The dentist documented that the resident needed surgical extractions of teeth #30 and #31 with sedation due to agitation, and provided a prescription for Clindamycin. The dentist also instructed that a referral to an oral surgeon be made for the extractions. Despite these orders, there was no evidence that the facility arranged the required referral or appointment with an oral surgeon. The DON, who ordered the antibiotic, could not confirm why the referral was not completed or documented, especially after the resident was sent to the hospital and subsequently readmitted. The facility's own policy required assistance with making dental appointments and documentation of any delays, but the record lacked evidence of these actions being taken for this resident.