Failure to Thoroughly Assess and Adequately Manage Dental Pain
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly assess and adequately manage dental pain for a resident with significant medical conditions. On 12/10/2025 at 11:00 a.m., the resident was observed in bed with dark areas in the mouth, a foul oral odor, and broken teeth with yellow to brown buildup. When asked, the resident reported having tooth pain. The resident’s records showed diagnoses including hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting the left dominant side, dysphagia (oropharyngeal phase), GERD, and gastrostomy status, with an NPO diet due to failed swallowing. The care plan in place included interventions for ADL self-care performance deficits, impaired mobility, impaired cognition, and hemiplegia, with oral care ordered every shift and more often if needed. The resident also had an order for pain management requiring evaluation every shift using a numerical or visual analog pain scale, and a PRN order for acetaminophen 325 mg two tablets via feeding tube every six hours as needed for pain, not to exceed 3000 mg in 24 hours. A care plan dated 4/23/2024 identified potential for pain with an intervention to administer medication per MD order for pain management. Despite these orders and the facility’s pain management policy requiring standardized assessment of pain (including onset, duration, location, severity, alleviating/aggravating factors, possible causes, and associated signs/symptoms using an appropriate pain assessment instrument), the documentation and observations did not demonstrate that the resident’s dental pain was thoroughly assessed in accordance with policy. The DON stated that nurses are expected to assess for pain and reported having assessed the resident for mouth pain and administering acetaminophen; however, the report identifies that pain was not thoroughly assessed and adequately treated for this resident’s tooth pain.
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