Failure to Arrange Oral Surgeon Follow-Up After Dental Referral
Penalty
Summary
The facility failed to ensure that a resident received necessary dental services, including follow-up with an oral surgeon after a dental referral. The resident’s POA reported that the resident’s teeth were hurting and was unsure if the resident had seen a dentist. Progress notes dated 07/30/25 documented that the resident had been seen by a dentist for a tooth extraction, that decay was present under the gum, the tooth broke, and that the resident needed to see an oral surgeon to extract the remaining portion of the tooth. Review of the medical record showed no documentation that the resident had been seen by an oral surgeon. Medical Records staff confirmed that the resident had been to the dentist on 07/30/25, that there was a referral to an oral surgeon, and that the resident had not been seen by the oral surgeon. The resident reported ongoing tooth pain, including pain when eating or drinking anything cold and when chewing on the side of the broken tooth, and stated that she was supposed to see an oral surgeon but the facility had not yet made an appointment. The DON confirmed that the resident had not seen an oral surgeon and stated that referrals should be followed up and appointments made.
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