Failure to Timely Refer Resident for Dental Services After Loss of Dentures
Penalty
Summary
The facility failed to assist a resident in obtaining routine and emergency dental care in a timely manner. The resident, an elderly male with Alzheimer's disease, chronic obstructive pulmonary disease, and a history of subdural hemorrhage, was admitted to the facility with his own teeth intact according to initial assessments and care plans. However, subsequent observations and interviews revealed that the resident had no upper or lower teeth and could not recall what happened to his dentures or missing teeth. Despite this, there was no documentation or prompt referral for dental services when the dentures were reported missing. Interviews with facility staff indicated a lack of communication and unclear responsibility regarding the referral process for dental care. The Assistant Director of Nursing (ADON) stated she was not informed about the missing dentures and believed it was the responsibility of the Social Worker (SW) to submit referrals. The SW reported receiving a verbal complaint from the resident's family about the missing dentures but could not provide documentation or a specific date for when a referral was made. The resident was not initially included on the list for upcoming dental appointments, and only after further inquiry was a referral form completed and the resident added to the list. Further interviews with the Director of Rehabilitation, Dietitian, and Administrator confirmed that there was no prior notification or assessment regarding the resident's missing dentures or need for a diet change. The resident continued on a regular diet without documented chewing or swallowing difficulties, and staff were unaware of the dental issue until it was brought to their attention during the survey. Facility policy required prompt referral and documentation for such issues, which was not followed in this case.