Incomplete policy for lost dentures: The facility failed to have a complete Dental Services policy addressing when it was responsible for replacing lost or broken dentures. A resident with intact cognition and a history including paraplegia, psychoactive substance abuse, MDD, and anxiety reported that staff removed the upper dentures, placed them on the bedside table, and the dentures later went missing after room cleaning. The resident’s care plan did not address denture storage or cleaning, and the Administrator confirmed the policy lacked a facility-specific protocol for lost or broken dentures.
Failure to provide routine dental services affected two residents. One resident with multiple neurologic and psychiatric diagnoses had documented oral/dental problems, but the record showed no dental visits for over a year and the DON confirmed no dental services since the last recorded exam. Another resident with diabetes, PVD, kidney disease, chronic pain, and anxiety had missing teeth and bone loss; after refusing the facility clinic dentist, there were no documented follow-up attempts to secure outside dental care, and staff interviews showed delays and missed scheduling opportunities.
A resident with COPD, dementia, anxiety, nicotine dependence, and a prior cerebral infarction remained edentulous and waited over a year for dentures. The care plan identified oral/dental risk, and progress notes showed repeated staff and NP follow-up with the dental clinic, but the resident still had not received dentures and continued to report concern about the delay. Staff interviews confirmed the resident was still without dentures and that the issue had been reported for follow-up.
Failure to provide timely dental services for a resident with DM, HTN, chronic pain, and malnutrition. The resident had impaired cognition, obvious or likely cavities or broken natural teeth, a loose tooth, and intermittent pain, with an order for dental evaluation and an order for Orajel for tooth and gum pain. Records and staff interview confirmed the resident had not been seen by the dentist since admission, despite the facility policy stating routine and emergency dental services were available.
A resident with broken teeth, dental pain, and diagnoses including DM2 and ataxia was not identified for dental services because the facility lacked a reliable process to determine which residents needed ancillary services. The resident said she had reported her pain to nursing staff, but no one had asked about dental care, and staff confirmed there was no documentation showing residents accepted or declined dental, vision, or hearing services; the resident was also not on the dental clinic list.
Failure to Arrange Dental Services: A resident with diabetes, CKD, and HTN had intact cognition but obvious dental problems, including missing teeth and root tips. She said she wanted to see a dentist and had difficulty chewing, yet the facility did not arrange dental care; staff noted the in-house dentist had not visited since before admission and an outside dental appointment could have been made for the non-Medicaid resident but was not.
Failure to assist residents in obtaining dental services. Two residents did not receive dental care despite documented needs and requests. One resident was edentulous, reported mouth pain and an open gum area, and said he wanted dentures but had not been offered dental care. Another resident with intact cognition said she had requested dental services and had not seen a dentist since admission, while staff could not produce evidence that she had declined care.
The facility failed to obtain dental services for a resident with Alzheimer's disease who had a signed consent for dental care and dentures. Although SS contacted the dental vendor to schedule appointments, the resident was not placed on the dental schedule, and SS stated there was no tracking process to ensure residents with signed consents were actually added to the dental list.
A resident with severe cognitive impairment, dysphagia, and dependence for care lost several teeth while eating, with scant bleeding noted and a detached bridge-like dental structure observed. A dental appt was scheduled, but the dentist could not complete the exam and referrals to other dentists were made. The chart lacked timely documentation of follow-up, and the resident’s rep did not receive clear communication about the outcome. Staff interviews showed confusion between transportation, nursing, and DHS about who was responsible for arranging the next dental visit.
Delayed Follow-Up for Dental Concerns: A resident with DM, HTN, CKD, anxiety, and lymphedema had documented broken and missing teeth, root tips, and oral/dental problems. Dental notes indicated the resident would benefit from full dentures and extractions, but follow-up was not completed after provider changes. The resident later reported tooth pain, mild facial swelling, and difficulty chewing, and staff confirmed he had not been scheduled with an oral surgeon.
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