Failure to Provide Timely Dental Services: A resident with dysphagia and HTN, who was cognitively intact and on Medicaid, had dental impressions taken for complete upper and lower dentures but then had no further documented follow-up with the dentist. The resident reported waiting a long time for dentures, had not received updates, and had not seen the dentist recently; the record showed no further communication after the initial dental consult and impressions.
A resident with type 2 DM and CHF reported not having dentures and said they had requested dentures several times. The clinical record showed no evidence that the facility arranged or followed up on dental services for a dental assessment or dentures, and the DSS confirmed there was no documentation of any further dental consults.
Failure to provide routine dental services for two residents was identified. One resident had several missing and broken teeth, a partial that no longer fit, and was being served cut-up food, while the other resident reported not seeing a dentist since admission and having multiple cavities. Both residents had care plans noting potential oral/dental issues, but there was no evidence the facility offered or assisted with dental care, and the DON and NHA confirmed the findings.
Failure to provide routine dental care and obtain needed dental clearances delayed treatment for two residents. One resident with encephalopathy had no documented routine dental evals and, after reporting a broken partial bridge and sharp pain, no dental appt or treatment was arranged by survey exit. Another resident with dementia and severe cognitive impairment had a broken molar with infection; although the dentist prescribed antibiotics and the physician clearance was completed, the record did not show the required consent forms were completed so the recommended extraction could proceed.
A resident with hydrocephalus and weakness reported mouth pain for months, but dental care was delayed despite repeated complaints to staff. The dentist initially evaluated the resident and planned extractions, but the procedure was postponed because consent was not obtained in time, and the resident was not scheduled for the next dental visit. The facility’s policy required assistance with routine and emergency ancillary services, including urgent dental treatment for pain.
Failure to provide routine dental services for two residents was identified. One resident had broken or likely cavity-affected natural teeth, a dental care plan, and limited dental documentation, but no evidence of twice-yearly professional dental services under the State plan. Another resident was edentulous, reported not being offered a dentist since admission, had ill-fitting dentures at home, and the facility could not produce documentation that dental services were offered despite a care plan noting dental consultation as needed.
Failure to provide ordered dentures to a resident. The resident reported being fitted for full upper and lower dentures but never receiving them, and said staff did not follow up. Dental consults documented the resident’s request for dentures and later recommended full upper and lower dentures, while the NHA confirmed the dentures were made but not released because of a payment dispute.
A resident with dementia, DM2, and PVD reported not having dentures and having requested them several times. Dental consults documented a need for full upper and lower dentures and follow-up to address the resident’s request, but the clinical record showed no evidence that the facility arranged or followed up on the dental services, and the Administrator confirmed there was no documentation of further dental consults.
A resident was seen by the contracted dental provider at bedside, and the provider recommended clinic follow-up for ultrasonic scaling with deposit remaining. The resident had diagnoses including HTN, vitamin D deficiency, and muscle weakness, and a resident representative later reported that the resident’s gums were very bloody. The DON confirmed that no dental clinic appointment had been made for the recommended follow-up.
A resident with heart failure, stroke, and diabetes had a lump on the gums reported by family, who provided a photo to the social worker. The social worker notified the care team and contacted the dental vendor, and later believed the dentist had evaluated the resident and determined the lump was an extra piece of bone not requiring surgery, while the family felt it impaired chewing and denture use. Documentation produced on request showed that the resident was not actually seen by the dentist, was not on the dentist’s final list, and that only a discussion with the family about a mandibular torus occurred; the form was unsigned and largely blank. The NHA confirmed the dentist never assessed the resident’s mouth, and the dental visit was not entered into the EHR, contrary to the facility’s dental services policy.
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