F0791

D

Failure to Coordinate and Secure Necessary Dental Services for a Dependent Resident

Marshville, North Carolina Survey Completed on 02-12-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure necessary assistance was provided to obtain routine and emergency dental services for a resident with significant cognitive and physical impairments. The resident was admitted with diagnoses including unspecified dementia, anoxic brain damage, unspecified intellectual disability, and hypertensive heart disease without heart failure, and required partial to substantial assistance with ADLs, including setup or clean-up assistance for oral hygiene and substantial assistance for transfers. The care plan dated 08/19/2025 did not identify any dental health problems, and the quarterly MDS documented no mouth or facial pain and no chewing discomfort, despite later reports from the POA that the resident complained of mouth pain and had difficulty chewing. Review of the EHR from 11/20/2024 through 07/09/2025 showed no evidence of a dental examination during that period.

The sequence of events shows multiple missed opportunities and breakdowns in coordination to secure needed dental treatment. The POA reported raising concerns about the resident’s dental needs beginning in April 2025, including observed discomfort while eating and verbal complaints of mouth pain, and stated he repeatedly informed the Social Worker and other staff. The POA ultimately scheduled the first dental appointment himself at Dental Office #1 on 07/10/2025. A Unit Manager note for that date indicated the resident returned from Dental Office #1 and was not seen due to inability to ambulate, but the dentist at Dental Office #1 reported that the resident was in fact seen, was found to have periodontal disease, and needed multiple extractions due to tooth decay and cavities. The dentist stated the resident’s teeth appeared not to have been properly cared for and that, due to their condition, the resident would have experienced pain. The dentist further stated he referred the resident to an oral and maxillofacial specialist (Dental Office #2) and placed the referral and instructions in the communication binder for the facility to call and schedule the appointment, but Dental Office #2 reported having no record of any contact or treatment for the resident.

Additional delays and failures occurred with subsequent dental arrangements. A Unit Manager note dated 07/29/2025 documented that the resident returned from Dental Office #3 with a diagnosis of gum disease and a need for multiple extractions, and a progress note dated 08/27/2025 indicated prior authorization was completed for Dental Office #3. However, the Chief Compliance Officer at Dental Office #3 stated the resident was only seen for a cleaning and X-ray at an initial appointment scheduled by the POA, and no treatment orders were communicated to the facility. The Social Worker stated she first learned of the dental concerns from the POA in July 2025, did not recall being told the resident was in pain, and believed dental services were being provided from August through September 2025 because she received no follow-up communication from nursing staff or the NP. She also stated there was no established process to follow up on outside dental appointments and could not provide documentation that the resident had ever been seen by the in-house dental provider, who visited quarterly and was present in October 2025. A Social Work note on 10/07/2025 documented that Dental Office #3 could not treat the resident unless he could transfer independently to the dental chair, and that an in-house dental appointment was scheduled for 10/17/2025, but the POA informed her of his intent to discharge the resident on 10/13/2025 due to delays in obtaining necessary dental services.

Staff interviews further highlighted communication and process failures that contributed to the deficiency. Unit Manager #1 acknowledged family concerns about the resident’s teeth and stated the resident required assistance transferring to a dental chair, but the facility lacked appropriate resources to assist with transfers at dental offices. She indicated that nursing and Social Work attempted to locate dental offices that could accommodate the resident’s transfer needs and that the appointment scheduler handled communication with Dental Office #1, but she was unaware of any referral to Dental Office #2. NA #3, who transported the resident to some appointments, stated she did not transport the resident to Dental Office #1 because she was on leave, transported him to Dental Office #3 on 08/27/2025, did not stay for the appointment, and had no equipment to facilitate safe transfers, learning from the POA that Dental Office #3 declined treatment because the resident could not transfer to the dental chair. The NP stated she completed authorization in August 2025 and believed delays were related to finding a facility that could accommodate the resident’s physical needs and accept his managed insurance. The DON and Administrator, both hired after the resident’s discharge, reported that the referral to Dental Office #2 may have been lost in communication and that they were not aware of the resident’s dental concerns at the time, while the Administrator stated he expects nursing and Social Work to follow up on residents’ dental needs.