Failure to Provide Timely Dental Consultation for Resident with Oral Pain
Penalty
Summary
Facility nursing staff failed to provide timely dental services after a resident reported significant oral pain. The resident, who had a history of hemiplegia following a stroke and documented missing or broken teeth, was cognitively able to report symptoms and did so, describing toothache, burning sensations in the upper and lower gums, difficulty chewing, and ongoing pain. An eInteract Change in Condition Evaluation completed by an RN on 3/9/2026 documented the resident’s report of toothache with burning gums, multiple missing and dark discolored teeth, cracked teeth, loss of lower teeth, and irritated gums. The physician was notified and a referral for a dental consultation was noted, and progress notes on 3/10/2026 indicated staff were monitoring the toothache and burning gum sensation, with gums described as slightly irritated and the resident continuing to report discomfort. Despite these findings and the facility’s Oral Healthcare & Dental Services policy stating that a consultant dentist would provide emergency dental care as needed, the actual dental consult was not scheduled until 3/16/2026, seven days after the initial complaint of oral pain. During interviews, the RD and an RN caring for the resident stated they were unaware of any issues with the resident’s teeth or chewing, and the DON confirmed the resident’s oral discomfort and that staff continued to administer pain medication. The DON acknowledged that nursing staff should have been more proactive in addressing the symptoms, which could indicate infection. A CT head and neck angiography performed at the hospital later showed numerous bilateral dental caries, and the dental consultant stated he would have expected immediate contact from staff upon the resident’s complaint of oral pain and emphasized the need for clear communication from the facility to his office. The resident reported still having pain during a subsequent interview.
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