Failure to Facilitate Necessary Dental Services for a Resident with Abscessed and Broken Teeth
Penalty
Summary
The facility failed to provide necessary routine and 24-hour emergency dental care for a resident who required dental services. The resident’s EMR documented diagnoses of GERD, major depressive disorder, and protein calorie malnutrition, with an admission MDS showing intact cognition and independence with oral hygiene. Initial assessments recorded that the resident did not have natural teeth or dentures and had recent weight loss, but lacked further dental documentation. A Dental Care CAA later recorded tooth pain on the right side and initiation of an antibiotic for a dental abscess. Nursing notes documented the resident’s report of a tooth abscess, mouth soreness, and pain, followed by an order for Clindamycin 300 mg four times daily for seven days and continued antibiotic treatment for abscessed teeth. Despite these documented dental issues and the facility’s Routine Dental Care policy requiring ongoing assessments, physician notification, and dental consultation as appropriate, the resident’s care plan contained no reference to broken or decayed teeth or to dental services to be provided. Observations showed the resident eating with missing teeth, one decayed and split tooth, and another broken off at the lower jaw. The Administrative Nurse confirmed she had not visualized the resident’s mouth or teeth until the survey date, verified the resident was edentulous except for two broken teeth, and acknowledged the resident was not on the facility’s dental services and had not received any dental care or services since admission, despite the facility’s policy outlining initial evaluation of dental needs, consultation with a dental consultant, and a daily oral hygiene plan of care.
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