Failure to Provide Routine and Follow-Up Dental Services
Penalty
Summary
Facility staff failed to ensure residents received required routine and follow-up dental care, resulting in missed or delayed dental assessments and services. One resident was observed during the initial tour to have few, if any, teeth, and review of the clinical record showed no dental consult in over a year, despite the requirement for at least an annual inspection of the mouth and jaw and diagnosis of any dental disease. When interviewed, the DON confirmed that there was no documentation of a dental consult or examination in the record and that the resident had not been seen by a dentist or dental company since 2023. Another resident with missing teeth and cavities had no clear documentation of routine dental services since admission. The record showed multiple attempted and completed dental encounters: an attempted visit where the resident was not found in the room or hallways, a completed dental exam with notation for a next-visit prophylaxis, and a later attempted dental hygiene encounter that could not be completed due to isolation. There was no documentation that this missed hygiene visit was rescheduled. A change in condition note documented that a left upper molar tooth came out while the resident was talking, with no bleeding or pain noted, and the resident was ordered to be seen by dental services. The last documented dental visit occurred after this tooth loss, and the surveyor identified that the recommended dental hygiene appointment had not been rescheduled following the missed visit.
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