Inaccurate MDS Dental Coding Due to Lack of Oral Assessment and Review of Dental Consult
Penalty
Summary
Surveyors identified a deficiency in accurate assessment and MDS coding for one resident related to dental status. The resident’s clinical record showed a quarterly MDS dated 2/11/25 in which Section L (Oral/Dental Status) was coded as no mouth or facial pain, discomfort, or difficulty chewing. A subsequent Dental Report of Consultation dated 3/23/25 documented recommendations to restore cavities and noted that teeth were extensively decayed with root tips that would need extraction in the future if symptoms or swelling began. Despite this, the 5/14/25 quarterly MDS again indicated no mouth or facial pain, discomfort, or difficulty chewing, and the 8/12/25 annual MDS Section L was coded as showing no cavities or broken natural teeth, no inflamed or bleeding gums, no loose natural teeth, and no mouth or facial pain or difficulty chewing. During interview, the RN MDS coordinator stated she completed the 8/12/25 MDS, confirmed she did not physically assess the resident’s teeth, and acknowledged she was not aware of the dental consult note or the dentist’s findings of decayed cavities and root tips recommended for extraction. The dentist reported that he did not personally check the resident’s teeth at that time and only saw the consult at the time of the survey, stating he had not been made aware of any dental issues by nursing staff. These actions and inactions resulted in inaccurate MDS coding of the resident’s oral/dental status over two review periods.
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