Inaccurate MDS Dental Assessment for Edentulous Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure an accurate Minimum Data Set (MDS) assessment for a resident’s dental status. Record review showed the resident was admitted on an unspecified date, and the family member reported that the resident had upper dentures and was missing lower dentures prior to admission. During observation and interview, the resident stated she did not have any teeth or dentures, reported she previously had dentures but was unsure what happened to them, and was observed without natural teeth or dentures. A CNA also stated the resident did not have any dentures. Despite these findings, review of the admission MDS revealed staff did not document that the resident was edentulous. The MDS Coordinator confirmed that the resident had neither her own teeth nor dentures since admission and acknowledged that the admission MDS was inaccurate because it failed to document the resident as edentulous.
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