Failure to provide follow-up dental services for a resident with missing and broken teeth. The resident reported severe dental problems, food avoidance, and sharp pain when biting, while a dental hygienist recommended referral for lower root tip extractions and a full upper denture. Staff acknowledged no dental appts were scheduled, the resident had anxiety about extractions, and there was no evidence of follow-up or contact with the prior dental office.
A resident with no natural teeth, diabetes, HF, and dysphagia remained without dentures despite repeated dental recommendations for new upper and lower dentures and a documented request process. Staff were unsure whether the request had been denied, later learned it had been denied for additional information, and acknowledged the denture issue had not been addressed sooner.
A resident with no natural teeth, dysphagia, and chewing/swallowing difficulty did not receive prompt dental services, and the oral health care plan did not match the resident’s current status. Staff said the dental referral was sent late, the dentist was in the facility but the resident was not seen, and the DON stated the need for dentures should have been addressed sooner.
A resident admitted after a stroke had documented broken and missing teeth, poor dentition, and a dysphagia diet, but the care plan contained only generic dental interventions and no individualized monitoring for the resident’s current dental issues. The resident reported sore teeth and gums, and observation showed broken teeth with reddened, swollen gum tissue. The chart had no documentation of a dental follow-up visit or pending appointment, and an ordered PRN oral gel for tooth pain was administered only once.
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.
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