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.
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 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.
A resident with significant dental needs and a history of malnutrition and failure to thrive was not referred for dental services, despite having only two teeth and being on a mechanically altered diet. Staff interviews confirmed that the resident was not offered dental care as required by facility procedures.
A resident with significant dental issues, including broken and decayed teeth and mouth pain, did not receive timely dental services despite a care plan and physician order for a dental consult. Although a referral for dental evaluation and extractions was made, there was no documentation that the referral was sent or that an appointment was scheduled, resulting in a prolonged lack of follow-up.
A resident with no natural teeth and medically complex conditions received new upper and lower dentures that were repeatedly described as too thick, ill-fitting, and uncomfortable, leading the resident to stop wearing them. The care plan required staff to coordinate dental care and transportation, and progress notes documented gum inflammation, an oral sore, pain, and ongoing refusal to wear the dentures. However, the record lacked documentation of the outcome of a key follow-up visit, any efforts to obtain an earlier appointment when problems persisted, or coordination of a later scheduled follow-up with the denturist, while the dentures remained unused in a denture cup and the resident continued to receive foods they reported difficulty chewing.
A resident with cerebral palsy, muscle weakness, and a urinary tract infection, who was able to express their needs, was observed to have multiple broken and discolored upper front teeth and reported ongoing dental issues. The resident's health record showed no dental consultation, plan, or treatment, and staff indicated the resident could not see the facility dentist due to their temporary status. Social services could not provide information about the resident's dental appointment status.
Two residents did not receive necessary dental services or follow-up. One resident with quadriplegia and other complex conditions had missing and stained teeth but had not seen a dentist since admission, despite provider orders and documentation of dental issues. Another resident, dependent on artificial feeding, needed lower dentures, but there was no care plan or dental consult in place. Staff interviews confirmed that the process for arranging dental care was not followed.
A resident with a broken tooth was not referred for dental services despite staff awareness and facility policy requiring such referrals. The resident experienced difficulty chewing, and interviews with nursing, social services, and the DON confirmed that no referral or documentation was made for dental care.
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