Failure to Provide Timely Follow-Up Dental Care After Identified Dental Needs
Penalty
Summary
The facility failed to promptly provide routine and emergency dental care for a resident who had documented dental needs following a dental examination. The facility’s policy on Dental Service Needs, dated 1/29/25, required nursing to collaborate with Social Services to secure dental resources and assist residents in making appointments. The resident was admitted on 11/25/22 and had a care plan initiated on 8/26/24 addressing independence with oral care, with a goal to remain free from dental complications and interventions that included performing oral exams as needed and referring to a dentist when indicated. On 3/23/25, a dental consultation documented recommendations for the resident to return to restore cavities and noted that extensively decayed teeth and root tips would need extraction in the future if symptoms or swelling began. Despite these recommendations, the resident’s quarterly MDS assessment on 5/14/25 indicated intact cognition and no dental issues, and there was no evidence that the resident was seen by the dentist for follow-up after the March 2025 exam. During an interview on 9/18/25, the resident reported not remembering being seen by a doctor, stated that their teeth were loose and falling out, and that this was affecting chewing and eating. The surveyor observed chipped and decayed teeth at that time. On 9/23/25, an LPN Unit Manager confirmed that the resident had not been seen by the dentist sooner after the March recommendation and stated that the resident was only on a list to be seen for a six‑month follow‑up visit. These findings were later discussed and reviewed with the NHA, DON, and Corporate Nurse on 9/29/25.
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