F0790

F

Failure to Coordinate and Follow Through on Dental Services and Recommendations

Glenwood, Illinois Survey Completed on 02-19-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide routine and 24-hour emergency dental care, follow its own dental services policy, implement care plan interventions, and ensure that dental recommendations were followed for three residents, potentially affecting 143 residents. For one resident with dementia and a BIMS score of 8, the care plan identified oral/dental problems related to edentulous tooth infection/pain and directed staff to coordinate dental care and monitor for symptoms. A handwritten note from the resident’s family requested a dental follow-up on a specific date, but there was no corresponding progress note documenting a dental visit or follow-up. Although a later progress note documented that the resident left for a dental appointment, the actual plan of care and follow-up information were not included, and the resident’s name did not appear on the facility’s dental list for several subsequent months. The Health Information Management Director reported not receiving information about the follow-up appointment, not knowing of any upcoming dental appointment for the resident, and having no communication with the resident’s daughter for approximately five months.

Another resident, cognitively intact with a BIMS score of 15, had a care plan noting dental/mouth problems and an intervention to consider a dental consult as indicated. Progress notes documented that the resident returned from a dental appointment with a referral for dentures, was scheduled to return for denture fitting, and was awaiting follow-up for upper denture fitting. A later dental consult documented that the upper quadrants had no teeth and did not indicate any denture steps selected. During observation, the resident appeared to be missing all upper teeth and reported that upper teeth had been removed months earlier, that the dentist had indicated three visits would be needed for denture fitting, and that the facility had not set up the necessary appointment. The Administrator stated that the dentist was not accepting the resident’s insurance and that only after obtaining a list of in-network providers were staff in the process of scheduling an appointment, indicating a prolonged delay between the referral and arranging denture services.

A third resident, with moderate cognitive impairment and a BIMS score of 9, had a prior dental consult indicating a well-fitting denture. A subsequent dental consult documented that the resident was a poor candidate for dentures due to lack of natural bone but could enroll for dental care at the facility to try a new denture. The Health Information Management Director stated that no one had provided any information about the need for new dentures, and the DON reported being unaware that the resident might require those services. The facility’s Dental Services policy, reviewed in the same time frame, required that documentation by the dentist be recorded in the medical record and that nursing document dental issues in the EMR. Interviews with the Social Service Director and DON described an expectation that residents be screened for dental services, that treatment plans be followed, and that dental orders and consults be communicated and documented, but the records and staff statements showed that these processes were not consistently carried out for the three residents.