Failure to Address Dental Needs in Care Plan
Penalty
Summary
The facility failed to develop and implement a care plan addressing the dental needs of a resident who was dependent on staff for all activities of daily living, including oral hygiene. The resident had multiple diagnoses, including Parkinson's disease, malnutrition, HIV, diabetes, and a history of adult physical abuse. Medical record review showed the resident was moderately cognitively impaired and required supervision with eating, as well as full assistance with personal care. The resident experienced mouth and facial pain, discomfort with chewing, and specifically reported a toothache in the right lower jaw. Hospice was notified, and the resident was started on antibiotics for a bacterial infection. A dental visit resulted in a referral for extractions, but review of the care plan revealed there was no documentation addressing the resident's dental needs, mouth pain, or the need for extractions. Staff interviews confirmed the absence of a care plan for these issues, despite the resident's ongoing dental pain and the need for intervention. Facility policy required care plans to be based on comprehensive assessments and developed by the interdisciplinary team, but this was not followed in the resident's case.