Tooth Extraction Performed Without Responsible Party Consent
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s Responsible Party (RP) was informed of the resident’s dental needs and that valid consent was obtained prior to a tooth extraction, despite the resident lacking decision-making capacity. The resident had diagnoses of metabolic encephalopathy and dementia, and the Minimum Data Set and History and Physical documented that the resident was not able to make reasonable and consistent decisions and did not have capacity to understand and make decisions. The resident required assistance with activities of daily living. A Dental Medical Order form proposed extraction of teeth numbers 12 and 29, and the attending physician signed this form to provide medical clearance, with instructions for the dentist to call the RP to explain the procedure. On the day of the procedure, the dentist proceeded with the extraction of tooth number 12 after explaining the procedure to the resident through LVN 1, who acted as a translator. The dentist obtained the resident’s signature on a Dental Procedure Consent form, which stated that the resident had read the consent and had questions answered to her satisfaction, and LVN 1 signed as a witness to the resident’s consent. The dental progress note documented that tooth number 12 was unrestorable and was extracted using forceps with local anesthetic, while tooth number 29 was not extracted. A Change of Condition evaluation recorded that the resident underwent extraction of tooth number 12. No documentation showed that the RP was contacted or that consent was obtained from the RP before the procedure. After the extraction, the RP complained that the tooth had been removed without her knowledge or consent and stated she had not been informed of the resident’s dental concerns or need for extraction by the dentist or nursing staff. LVN 1 acknowledged that she did not call the RP or check the medical record to verify the resident’s capacity or the need for RP consent, assuming this had already been done. The Registered Nurse Supervisor reported that he declined to witness the consent after the procedure because he knew the resident lacked capacity and that the family was responsible for healthcare decisions. The dentist stated he did not call the RP, assumed the dental office had contacted the family, did not verify the resident’s cognition or capacity, and noted that the face sheet did not indicate a designated RP. Facility policies on notification of changes, informed consent, resident rights, and dental services required that resident representatives be informed and involved in decisions and that informed consent be verified prior to treatment, and the Dental Facilities Services Agreement required the dentist to maintain legal informed consent signed by residents and/or their responsible parties.
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