Failure to Provide Timely Dental Services and Oral Surgery Referral
Penalty
Summary
The facility failed to ensure that dental services were provided to a resident who required such care, as outlined in the facility's dental services policy. The resident, who had a history of cerebral aneurysm, anxiety, and depression, was identified as needing multiple teeth extractions and a referral to an oral maxillofacial surgeon. Documentation showed that dental providers recommended referrals on two separate occasions, and resources for Medicaid coverage were sent to the facility. Despite these recommendations and the facility's policy assigning responsibility to social services for assisting with appointments, the resident had not been seen by an oral surgeon over an extended period. Medical record reviews indicated that attempts were made to schedule the referral, but there was no evidence that an appointment was successfully arranged or completed. The resident's care plan noted the need for dental care coordination, and the resident was cognitively intact and aware of the delay, stating they had been told about the need for extractions and dentures about a year prior. Interviews with facility staff revealed uncertainty and lack of documentation regarding the referral process, with the Social Services Director unable to find relevant notes and the DON confirming that follow-up should have occurred.