F0684

D

Failure to Arrange Follow-Up Dental Care for Resident with Ongoing Oral Pain

Galena, Illinois Survey Completed on 03-11-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide appropriate treatment and care according to physician orders and the resident’s preferences and goals by not ensuring a follow-up dental visit for a resident experiencing oral pain. The resident had multiple diagnoses, including congestive heart failure, Type 2 diabetes, Alzheimer’s disease, major depressive disorder, hypertension, and schizotypal disorder, but the facility assessment documented no cognitive impairment and noted delusions. The resident reported having seen a dentist the prior month, being told that four upper teeth needed extraction, receiving antibiotics from a hospital for suspected infection, and relying on ibuprofen for pain relief. Medication administration records showed the resident received ibuprofen and Tylenol 15 times for oral pain over a little more than a month, with most doses occurring in the latter part of that period.

Dental records from the 2/19 visit documented that the resident presented with upper anterior tooth pain, had a periapical x-ray showing decay and a periapical radiolucency on tooth #10, and was referred to an oral surgeon for extraction, with a recommendation to return for a full exam and further evaluation of other teeth. The dentist office scheduler later confirmed that the resident had been seen for an urgent care appointment, that oral surgery was needed, and that the resident was a no-show for a scheduled follow-up appointment on 3/4, with no subsequent contact from the facility or the resident to reschedule. Facility staff interviews revealed that the resident had left with a friend for the 2/19 appointment instead of using arranged transportation and returned without any paperwork, leaving staff unaware of what was done or what follow-up was required.

Nursing, transportation, social services, and administrative staff provided conflicting and incomplete accounts regarding responsibility for arranging and rescheduling the follow-up dental appointment. Nurses stated that the transportation company required an escort and that the appointment was cancelled when no staff were available to ride with the resident, and that the resident subsequently called 911 seeking transport, resulting instead in a hospital visit. The transportation staff member stated that the resident had independently arranged the follow-up appointment and transportation, but that the facility cancelled on the day of the appointment due to lack of an escort and did not reschedule because no paperwork had been received from the prior visit. The Social Service Director and Administrator both acknowledged that the resident returned from the 2/19 appointment without paperwork and that there were no further appointments scheduled, with the Administrator indicating a belief that the appointment was only for a cleaning and did not need rescheduling. The DON stated that nurses should follow up with providers when residents return without paperwork and that any missed follow-up appointment should have been rescheduled. The facility’s resident appointment policy contained no guidance on staff responsibilities when a resident returns from an appointment without documentation.