Failure to Arrange Recommended Dental Extractions and Ongoing Dental Care
Penalty
Summary
Failure to obtain routine and emergency dental services occurred when a cognitively intact resident, admitted in 2020 and discharged in 2026 with diagnoses including hemiplegia, hemiparesis, cerebral infarction, and COPD, did not receive recommended dental treatment or ongoing dental care. A dental exam performed by an outside provider in April 2024 documented a referral for extraction of teeth #3, 8, 9, and 14, and the associated patient referral form specified extractions of those teeth. No additional dental service notes or documentation of completed extractions were found in the facility records after that visit. Email correspondence from the contracted dental provider in February 2026 confirmed that the last notes for this resident were from 2024 and that the resident was not enrolled in the dental program, meaning she would not be seen regularly unless the facility or family submitted a request. Interviews with facility staff further showed that the facility did not follow through on arranging the recommended extractions or ensuring ongoing dental services. The dental provider’s clinical support stated that after the April 2024 exam and recommendation for extractions, they never heard anything further and that it was the facility’s responsibility to take the referral to an outside dental office and schedule care. The Social Services Director stated the resident was on Medicaid and should be scheduled to see a dentist at least yearly, with nursing notifying Social Services when appointments were needed. The DON acknowledged that if the last dental service was in 2024, the resident did not receive dental services for the entire year of 2025. The Assistant Administrator reported that the facility had no dental services policy and procedure regarding frequency of services, and an undated facility document stated residents would be seen on an as-needed basis, while residents’ rights materials stated the facility must provide services to keep residents’ physical and mental health at their highest practicable levels.
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