A resident with dementia, hearing loss, and missing lower teeth had an MDS showing obvious or likely cavities or broken natural teeth, and the care plan identified oral/dental health problems with an intervention to coordinate dental care and transportation. Staff stated the resident’s dental needs were captured on the MDS, but no referral was made for dental services or follow-up with the dentist, and the DON said the lack of referral did not meet expectations.
Failure to address a resident’s denture needs. A resident with damaged lower teeth and no upper teeth stated their upper denture was at home, but the denture need was not included in the care plan. The MDS identified the resident as edentulous, and the nutritional assessment noted missing teeth, absent dentures, and risk for altered nutrition/hydration status related to missing teeth. An RCM/LPN and the Regional Director of QA both stated the resident’s dental needs should have been included in the plan of care and that the resident should have been referred for new dentures.
A resident with COPD and diabetes reported dentures that did not fit and said they had seen a dentist for new dentures but had not heard anything further. Records showed a dental note recommending new upper and lower dentures and extractions, and another note stating the resident needed referral out for x-rays and extractions for all lower teeth. Staff interviews showed the transportation specialist had not seen the denture recommendation and believed only a recall exam was scheduled, while the unit care coordinator had not received notice that the follow-up was completed.
Failure to follow up on a resident’s dental referral resulted in no documented completion of x-rays, evaluation for tooth extraction, or referral for new dentures. The resident had mouth/facial pain and difficulty chewing, reported broken and missing teeth, and the care plan directed staff to coordinate dental care and transportation as needed. The DON confirmed there was no documentation of follow-up on the dental consult.
Failure to Provide Routine Dental Services: Two residents had unmet dental needs, including broken and missing teeth, pain, and difficulty chewing. One resident with quadriplegia had a prior dental exam showing broken teeth, irritated gums, and referrals for x-rays and extractions, but the issue was not care planned. Another resident had missing and broken upper teeth with tooth pain affecting eating, and staff could not locate a dental referral despite monthly dental provider visits and the DON stating the resident should have been referred and care planned.
A resident with anxiety disorder, dementia, and schizophrenia reported that dentures left behind when moving into the facility were never retrieved. An outside dental provider documented the resident wanted a new set of dentures ASAP, but the care plan only noted no teeth and a referral to a dentist as needed, with no documentation of the denture need. Staff were unsure whether the request was followed up, and no dental appointments were scheduled after the request.
Failure to obtain and provide routine dental services for a resident with dysphagia and poor dentition. The resident reported broken, falling-apart teeth, difficulty eating at times, and said they had not been offered a dental visit. Records showed no upper teeth, many missing and broken lower teeth, a mechanically altered diet, and a care plan noting oral/dental problems. Staff said dental needs were discussed but not documented, and no dental care documentation was found.
Failure to provide dental services for a resident with broken and missing teeth and oral pain. The resident’s MDS showed cavities or broken teeth and mouth/facial pain, and records documented no upper teeth, poor lower dentition, chewing and swallowing difficulty, and a pureed diet. The care plan called for coordination of dental care, but the chart had no dental referral, and staff stated no provider notification or dental exam/referral could be found.
Failure to follow through on dental referrals and routine dental care for multiple residents. A resident with dementia had not been added to the dental list or seen by a dentist after admission, another resident with impaired cognition had broken dentures and unmet orders for new dentures with no clear tracking process, and a third resident with stroke had abnormal tongue findings and denture orders that staff had not reviewed or completed.
Failure to Provide Routine Dental Care: A resident with CKD, AFib, and HF reported a lost tooth, multiple missing teeth, and a filling that fell out, but no dental consults were documented and the care plan did not address dental needs. The RN/MDS stated the resident needed a referral for dental services, and the DON said the records did not meet expectations.
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