Failure to Coordinate and Document Timely Dental Services for a Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely provision and coordination of dental services for a resident who required dentures. The resident, admitted with multiple medical diagnoses including COPD, hemiplegia, CHF, major depressive disorder, anxiety disorder, dementia, hallucinations, and muscle weakness, reported via a concern form that his dentures were missing. The concern form documented that the dentures were later found broken and lodged in a toilet, and that the resident’s guardian was notified and indicated they would contact the dental company for the resident to be seen by a dentist. The resident’s care plan, dated shortly after this event, directed staff to monitor and notify the medical provider as needed for oral/dental problems and stated that the facility would coordinate arrangements for dental care and transportation as needed or ordered. Despite these care plan directives and the identified need for dental services, review of progress notes from early November through early January showed no documentation of any dental visits for the resident and no documentation of attempts to contact the guardian regarding dental care. In an interview, the Social Service Director confirmed that there were no documented guardian contact attempts in the medical record during this period and stated that the guardian was required to complete a dental consent form for the resident to receive dental care at the facility. The Social Service Director reported that the guardian was last contacted in mid-November and given information on the consent form but acknowledged that this contact was not documented and that there were no further contacts with the guardian through early January. The Social Service Director also stated they were unaware of any facility policy specifying how many times a guardian should be contacted to resolve resident issues.
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