Delayed Dental Evaluation and Ongoing Oral Pain
Summary
The facility failed to ensure a dental evaluation was completed in a timely manner for one resident, resulting in prolonged oral pain, facial swelling, delay in starting SLP therapy, and the resident remaining on a pureed diet. The resident had diagnoses including type 2 diabetes with foot ulcer and hemiplegia/hemiparesis following cerebral infarction affecting the right dominant side, and the MDS showed the resident needed assistance with most ADLs and had moderately impaired cognition. The care plan identified nutritional/hydration concerns, recent weight loss, a history of oral thrush, mouth pain, and a dental consult already in place. The record showed repeated documentation of mouth pain, facial swelling, difficulty chewing, and swallowing concerns over several months. Nursing, physician, NP, dietary, and SLP notes described oral pain, white patches consistent with candidal stomatitis, dry mouth, sinus pain, swelling of the cheeks, and difficulty swallowing. The resident was treated with nystatin and antibiotics, and the diet was downgraded to liquids and then maintained at a pureed texture because the resident disliked pureed food but could not tolerate texture advancement due to mouth pain and chewing difficulty. SLP repeatedly documented that therapy could not progress because the resident continued to report dental and sinus pain and refused or spit out mechanical soft trials due to difficulty chewing. A dental evaluation was not completed until months after the dental consult order was placed, and that evaluation found poor teeth condition, heavy plaque and calculus, severe gingivitis, poor periodontal condition, high caries risk, and retained roots with referral to oral surgery for extraction of all remaining root tips. The record did not show that an oral surgery appointment was made during the resident’s stay, and staff interviews confirmed the delay in obtaining dental evaluation and the lack of an oral surgery appointment.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to arrange dental care for a resident with no upper teeth and only a few lower teeth. The resident said they wanted dentures and had difficulty eating, but the dental assessment and referral noted a need to question upper dentures and a lower partial, and the EMR showed no follow-up. An LPN was unaware of the resident’s denture request, and an RN said dental care was not typically addressed quarterly during care conferences.
A resident with COPD, CHF, personality disorder, and morbid obesity was bedbound and needed outside dental care for sedation and removal of remaining teeth. An outside dental appt was set up, but the transportation office canceled the ride, and there was no evidence the appt was rescheduled. The resident said her teeth were bad and broken off and that she wanted to see a dentist to have them pulled.
Failure to provide routine dental services for a resident after a refused dental visit. The resident had not seen a dentist since admission, and after refusing one scheduled dental appt, no further dental appts were scheduled or offered. The ADON and DON confirmed the resident was not seen by a dentist again prior to survey intervention.
Failure to provide timely dental services: A resident with mouth and tooth pain was treated with antibiotics and a dental consult was ordered, but the resident remained awaiting dental evaluation for definitive care. The resident and complainant stated the resident had not seen a dentist, and staff reported problems arranging the appointment due to insurance issues and changes in who handled scheduling; the BOM said there was no reason the resident should not have been seen, and the DON confirmed the findings.
A resident with Parkinson’s disease and PVD had a fractured tooth that was evaluated by a mobile dental provider and the in-house dentist, who recommended extraction and prescribed antibiotics and pain medication. After physician approval and family consent, the extraction still was not completed because local oral surgeons would not accept Medicaid, the family was told to pay privately or change plans, and the record did not show coordination with a distant dental office or clear communication about transportation. The resident and family said transportation was never offered, and the resident remained without the recommended extraction for 8 months before death.
A resident with CKD and PVD, who was cognitively intact, had multiple non-restorable teeth and retained root tips with a plan for extractions so dentures could be made. Although medical clearance was obtained and staff noted the procedure would be scheduled, the record showed no completed extractions, no documentation explaining the delay, and no evidence the procedure had been scheduled during the survey period. The resident reported intermittent tooth pain for months while waiting for the dental work.
Failure to Arrange Dental Care for Resident Needing Dentures
Penalty
Summary
The facility failed to provide arrangements for dental care for one resident who had moderate cognitive impairment and required staff assistance with ADLs. The resident’s care plan noted a self-care deficit related to impaired mobility and stated the resident was usually independent with oral care but needed assistance at times. The resident’s order summary showed a renal diet with level 7 regular texture. During interview, the resident stated they had no upper teeth and only a couple of lower teeth, had been wanting dentures, had not gotten any, and that eating was difficult at times. The resident’s oral/dental assessment indicated no upper teeth or dentures, only two lower teeth, and no dentures. The dental care referral recommendations called for a routine dental referral and noted non-urgent dental care needs, with a question to nursing staff about upper dentures and a lower partial. Review of the EMR did not identify follow-up on the question of upper dentures and lower partial dentures. An LPN stated they were not aware the resident wanted dentures, and an RN stated the resident had been screened by the facility, had previously been seen by an outside dental office but not since 2004, and became tearful when asked if they wanted to be seen for dentures. The RN also stated dental care was not typically addressed quarterly during care conferences.
Failure to Arrange Dental Appointment and Transportation
Penalty
Summary
The facility failed to assist a resident in making and keeping an outside dental appointment and in arranging transportation to and from the dental service location to obtain dental care. Resident #22 was admitted with diagnoses including COPD, CHF, personality disorder, and morbid obesity, and an onsite dental consult noted the resident was bedbound and needed referral out for sedation and removal of the remaining teeth. Nursing documentation showed an outside dental appointment was set up, but on the day of the appointment the transportation office canceled the ride, and the nurse contacted the scheduler to reschedule. However, there was no evidence that another outside dental appointment had been scheduled by the time of the survey. The resident’s MDS indicated intact cognition, and the resident stated her teeth were bad and broken off and that she wanted to see a dentist to have her teeth pulled.
Failure to Provide Routine Dental Services
Penalty
Summary
The facility failed to provide routine dental services for one resident who had been admitted since August 2024. The resident stated that they had not seen a dentist since admission. The medical record showed a dental appointment was scheduled in November 2024, but the resident refused the visit, and no later dental appointments were scheduled or completed after that refusal. The ADON confirmed the resident was not placed back on the dental provider’s schedule and had not been offered another routine dental appointment, and the DON stated the resident had not been offered or seen by a dentist during 2025 or 2026 prior to survey intervention.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to ensure that a resident who required dental services on a routine or emergent basis received necessary or recommended dental care in a timely manner. After the resident complained of pain on the left side of the mouth, the physician was notified and ordered an antibiotic and a dental consult. A later physician progress note documented that the resident had completed the antibiotic for left tooth pain and that a dental consult had been ordered, with the resident still awaiting dental evaluation for definitive care. A subsequent NP note documented management of antibiotics for a tooth infection and stated that the resident reported the tooth ache was improving but was frustrated about not being able to see the dentist. The NP documented possible dental infection and the need to follow up with a dentist for source control. During interviews, the complainant and the resident stated that the resident had not seen a dentist, and staff reported problems with arranging the appointment, including issues with insurance and the loss of the person who previously made dental appointments. The BOM stated Medicaid had been approved and there was no reason the resident should not have been seen by the dentist, while the DON confirmed the findings.
Failure to Obtain Timely Dental Extraction
Penalty
Summary
The facility failed to provide or obtain timely medically necessary dental services for a resident with Parkinson’s disease and peripheral vascular disease after a fractured tooth was identified. The resident’s clinical record showed that a mobile dental provider and then the in-house dentist evaluated the resident, documented pain involving tooth number 4, obtained x-rays, and recommended extraction. The dentist prescribed antibiotics and pain medication, and later again recommended extraction when the tooth remained fractured and the resident continued to report discomfort. After physician approval and resident representative consent were documented, the extraction still was not completed. Social Services documented that several local oral surgeons were contacted but did not accept the resident’s Medicaid coverage, and the family was told they could change Medicaid plans or pay privately, which they declined. Nursing later documented that the antibiotic was discontinued because the procedure had been cancelled. The record did not show that the facility developed or implemented an alternative plan to obtain the extraction after the cancellation. The record also did not show that the facility coordinated treatment with the mobile dental office located approximately 92 miles away, arranged transportation, communicated transportation options to the family, or documented additional efforts to overcome the barriers related to provider availability, transportation, insurance coverage, and required documentation. During interviews, Social Services stated the family did not want the resident to travel that far, while the Nursing Home Administrator stated the facility would have transported the resident at no cost. The resident representative and the resident’s son stated they were never informed transportation would be provided and believed it was their responsibility to get him to the appointment. The resident remained without the recommended extraction for 8 months before death.
Delayed Dental Extractions and Lack of Documentation
Penalty
Summary
The facility failed to ensure timely access to necessary dental services for one Medicaid resident. Resident 17 was admitted with chronic kidney disease and peripheral vascular disease and was cognitively intact on the annual MDS with a BIMS score of 14. An external dental progress note documented multiple non-restorable teeth and retained root tips, and the resident agreed to extraction of six teeth and retained root tips so dentures could be fabricated. A physician clearance form documented medical clearance for extraction of teeth numbered 13, 15, 26, 27, and 28 and instructed staff to hold Aspirin 81 mg for five days before the procedure. A nursing progress note later documented that external dental services evaluated Resident 17 and that a date for multiple tooth extractions would be scheduled, but the clinical record contained no documentation that the planned extractions were completed. The record also lacked documentation explaining the delay or showing ongoing efforts to obtain the dental services, and there was no documented evidence that the extractions had been scheduled during the period from the dental evaluation through the survey. During interview, Resident 17 stated he had experienced intermittent tooth pain for several months related to cracked teeth and had been waiting for the planned extractions so dentures could be made. The DON and NHA were unable to provide documentation explaining the delay or showing that the procedure had been scheduled until after the survey team requested supporting information.
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