Failure to Ensure Dental Assessment for Resident With Oral Lump
Penalty
Summary
The facility failed to ensure that a resident received an appropriate dental assessment in accordance with its Dental Services Policy, which states that the facility will assist residents in obtaining routine and 24-hour emergency dental care and that all dental services will be recorded or scanned into the medical record. The resident, identified as R14, was admitted to the facility and had documented diagnoses including heart failure, stroke, and diabetes. A progress note indicated that the social worker spoke with the resident’s family, who showed a picture of a lump on the resident’s gum. The social worker discussed this concern with the care team and contacted the dental vendor to schedule a dentist visit. The social worker later reported that the resident had been seen by the dentist and that the dentist considered the lump to be an extra piece of bone not requiring surgical intervention, while the family believed the lump affected the resident’s ability to chew and wear dentures. When the surveyor requested the dental exam, the facility produced a form not scanned into the electronic health record, which documented a date of service but stated that the resident was not seen and was not on the dentist’s final list. The form indicated that the dentist only spoke with the family about a mandibular torus and that the resident would need an oral surgeon for removal, but it was not signed by the dentist and was left otherwise blank. The Nursing Home Administrator confirmed that the dentist never actually saw or assessed the resident’s mouth, demonstrating that the resident did not receive the dental assessment required by facility policy and state nursing services regulations.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.