Failure to Assist Resident in Obtaining Needed Emergency Dental Services
Penalty
Summary
The deficiency involves the facility’s failure to assist a resident in obtaining needed emergency dental services despite ongoing severe tooth pain and documented need for a root canal or extraction. The resident reported right molar pain rated 9 out of 10, with symptoms beginning months earlier when the tooth began to chip. During a routine dental visit, the resident was informed that a root canal extraction procedure was needed to manage the tooth pain. An infectious disease progress note documented that the resident had a right lower tooth infection, was prescribed Amoxicillin 500 mg TID for seven days, and still had persistent pain with a chipped tooth, with a root canal pending insurance approval and a need to follow up with the dentist. The resident stated that the tooth had become more chipped and increasingly uncomfortable, especially when eating, and that he repeatedly tried to follow up with the social worker for assistance with the dental referral but was still waiting for an update. The social worker acknowledged being responsible for assisting residents with outside dental referral services and confirmed he was informed months earlier about this resident’s needed dental procedure. He stated that due to difficulties related to the resident’s Medicaid insurance, he stopped assisting with the referral because he was unsure how else to help and instead told the resident to contact his insurance directly. The social worker did not document any referral attempts in the EMR, did not include the dental consultation assessment or extraction referral from the earlier dental visit, and did not discuss the resident’s dental needs with the administrator. The EMR contained an active order allowing the resident to receive dental and other specialist services as deemed necessary, but there were no further progress notes showing staff follow-up or assistance with the resident’s dental care needs. The facility’s policy on routine dental care required ongoing oral health assessments, physician notification of dental treatment needs, and inclusion of dental findings in the medical record, but the documented actions and omissions show that these processes were not carried out for this resident’s dental problem.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.