A resident with stroke, chronic pain, trigeminal neuralgia, and bruxism had multiple dental orders for eval and treatment by the facility dentist, including for teeth grinding, but had not been seen by a dentist since admission. The resident reported no dental visit, and the MDS/scheduler confirmed the resident had not been seen despite the facility having dental services available.
Failure to obtain routine dental services for a resident with ill-fitting dentures and an edentulous mouth. Oral screenings repeatedly identified the need for a dental consult, but no documented dental visit was found since admission. The DON stated the resident had not been enrolled in the outside dental program and that this was an oversight.
A resident needed dental extractions and was initially told the safest course was oral surgery under GA in a hospital setting, but the referral was not acted on for months. In-house dental notes later continued to recommend FMX, extractions of retained roots, and dentures, yet x-rays were not completed and extraction attempts were unsuccessful; the DON acknowledged the hospital oral surgery process was not started until much later.
A resident reported needing dental cleaning and waiting months for the facility to make an appointment. The record showed a physician ordered a referral for dental care, but follow-up remained pending and the resident was still unaware of any appointment. The DON stated the resident had previously refused dental services, but did not explain why the later order was not addressed.
A facility failed to ensure timely dental services for two residents. One resident had repeated reports of tooth pain, provider notes documenting a pending dental consult, and only later had a dental appointment arranged by family. Another resident reported needing dentures, and MDS assessments showed obvious or likely cavity or broken natural teeth, but the Administrator could not find documentation of any follow-up dental care.
Facility staff failed to ensure two residents received required routine and follow-up dental care. One resident, observed to have few or no teeth, had no documented dental consult for over a year and had not been seen by a dentist since the prior year, despite requirements for at least annual oral assessments. Another resident with missing teeth and cavities had sporadic dental encounters, including attempted visits where the resident was unavailable or in isolation, and a recommended dental hygiene visit that was never rescheduled. A nursing note documented that a molar tooth came out while the resident was talking, and the resident was ordered to be seen by dental services, with the next documented dental visit occurring only after this event.
A resident with no teeth or dentures reported discomfort from chewing on their gums, and the surveyor observed the resident eating breakfast without teeth. Record review showed multiple dental/oral evaluations that did not mention a pending consult, while the resident’s last dental appointment was for extractions and an earlier dental consult recommended scheduling dental surgery and then starting the denture process.
A resident reviewed for dental concerns had no documented dental consults since admission. The DON stated that no dental visit was obtained because there were no complaints from the resident or family, even though an outside dental evaluation was required on an annual basis.
Failure to obtain routine dental services for a resident with poor dentition, missing teeth, poor oral care, and a tooth with internal black/grey discoloration. The resident stated he/she had not been seen by a dentist since admission and wanted to see the dentist. Record review found no documentation of routine or emergent dental visits, and an LPN and the DON were unable to provide documentation of any dental service for the resident.
A resident did not receive routine dental services, and the resident reported not seeing a dentist or having a dentist visit the facility for over a year. The Unit Manager said staff only call the dentist when residents complain or show a need, and the clinical record contained no dental consult or dental visit. The DON also could not find any record that the resident had ever gone to the dentist.
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