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.
A resident with dementia and chronic kidney disease lost an upper denture, which staff documented and searched for but could not locate. Despite a facility policy requiring referral for lost dentures within three days and existing care plan and MD orders for dental consults as needed, a dental referral was not made for over a month, and the resident was not seen by a dentist until later for an impression for a new denture. During this delay, SLP notes documented decreased PO intake, difficulty chewing, diet downgrades to puree and then mechanical soft, and ongoing complaints about inability to chew and dislike of the softer diet. The resident was observed eating without the denture and experienced notable weight loss over this period, while the DON acknowledged an expectation for timely dental consultations for missing dentures.
The facility failed to ensure that dental services and dentist recommendations were provided and implemented for three residents. One resident with dementia and progressive multiple sclerosis had a dental consult recommending a special fluoride gel and an oral surgeon referral, but no corresponding physician orders or nursing review were found. Another resident with vascular dementia and muscle weakness lost upper and lower dentures; although Step 1 of denture replacement was documented and a follow-up was scheduled, no further dental notes appeared in the record despite repeated inquiries from the resident’s representative, and the DON confirmed the dentist had not seen the resident again. A third resident with a neurocognitive disorder and heart failure had a periodic oral exam with a prophylaxis visit scheduled, but no subsequent dental documentation existed, indicating that planned routine dental care was not completed or recorded.
A cognitively intact long-term resident with Medicaid coverage reported not having seen a dentist since admission and experiencing tooth pain requiring extraction. Review of records showed no evidence of any dental visits or scheduled routine dental exams from admission through the time of review, and no documentation that the resident refused dental care. A Unit Manager confirmed that the resident had not seen a dentist or had a dental consult and that an appointment was only scheduled after the resident reported tooth pain, indicating a failure to provide routine dental services as required.
A resident with chronic medical conditions and a documented risk for oral health problems did not receive routine dental services as required by facility policy. Review of the clinical record and staff confirmation showed no dental consultations or access to routine or emergency dental care since admission.
A resident with Alzheimer's disease and other mental health diagnoses did not receive timely dental services for denture replacement, despite multiple scheduled visits and documented need for assistance with dentures. The resident missed a key denture fitting appointment, and the dentist was unable to locate her during a scheduled visit, resulting in a delay in necessary dental care.
Two residents who requested or required dental care were not scheduled for dental appointments, despite one having a physician order for a dental consult and the other reporting discomfort with dentures. Staff interviews confirmed the facility did not follow its process for obtaining dental services, resulting in these residents not being seen by the contracted dental provider.
The facility did not provide or obtain necessary dental services for a resident, resulting in a deficiency related to unmet dental care needs.
A resident with multiple medical conditions had all lower teeth extracted and was left without lower dentures for nearly a year, despite repeated documentation by clinical staff and physician orders to follow up with dental services. The resident experienced ongoing eating difficulties and dissatisfaction, and interviews confirmed the delay in receiving dentures.
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