The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property.
F272 ß483.20, 483.20(b) Comprehensive Assessments
The facility must conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity.
A facility must make a comprehensive assessment of a resident's needs, using the RAI specified by the State. The assessment must include at least the following: Identification and demographic information; Customary routine; Cognitive patterns; Communication; Vision; Mood and behavior patterns; Psychosocial well-being; Physical functioning and structural problems; Continence; Disease diagnosis and health conditions; Dental and nutritional status; Skin conditions; Activity pursuit; Medications; Special treatments and procedures; Discharge potential; Documentation of summary information regarding the additional assessment performed through the resident assessment protocols; and Documentation of participation in assessment.
F411 ß483.55(a) Dental Services-SNF
The facility must assist residents in obtaining routine and 24-hour emergency dental care.
A facility must provide or obtain from an outside resource, in accordance with ß483.75(h) of this part, routine and emergency dental services to meet the needs of each resident; may charge a Medicare resident an additional amount for routine and emergency dental services; must if necessary, assist the resident in making appointments; and by arranging for transportation to and from the dentist's office; and promptly refer residents with lost or damaged dentures to a dentist.
The facility failed to assess Resident 1 for dental status and failed to provide routine dental services to ensure oral/dental health resulting in the resident's death, on 3/12/07, related to septicemia and cardio respiratory arrest.
Resident 1 was transferred to the acute care hospital at 5:30 p.m. on 3/4/07, for right neck swelling which was diagnosed as cellulitis and sepsis.
On 3/14/07, clinical record review revealed the following:
Resident 1, a 76 year-old female, was admitted to the facility on 8/18/05 with diagnoses including Alzheimer's disease.
The most recent full Minimum Data Set assessment, dated 8/25/06, documented Resident 1 as having severely impaired cognitive skills and needing total assistance with personal hygiene. Oral/dental status indicated that the resident needed daily cleaning of teeth/dentures, or daily mouth care. The MDS did not include the information that the resident had lost some of her natural teeth.
Review of care plans revealed a problem identified as "risk for dehydration related to dementia, Alzheimer's, on diuretic. . .". Interventions included "encourage oral hygiene to promote interest in drinking." There was no documented evidence of a specific care plan for oral care which included care of the resident's natural teeth and permanent bridge. The care plan did not indicate a problem related to dental caries as identified on the admission History and Physical on 3/04/07, when the resident was admitted to the acute care hospital.
The clinical record lacked any documentation that the resident had a routine dental exam between admission on 8/18/05 and hospital admission on 3/04/07. The Social Service Designee stated, during an interview on 3/15/07 at 1 p.m., that no dental exam had been done because, "the facility thought the resident had dentures."
Review of the Nurses Notes revealed the following:
On 3/4/07 at 6 a.m., the nurse documented the resident was highly febrile (103.0 Fahrenheit). by10 a.m., swollen lymph nodes, R (right side), were noted. At 2 p.m. on the same date, Nurses Notes documented that the facility "called MD about the swollen lymph nodes R side of the neck, Septra DS, started from E-kit, for CBC [complete blood count], CXR [chest x-ray], + UA [urinary analysis] c [with] C&S [culture and sensitivity]",
At 5:30 p.m., the resident was observed with swollen lymph nodes right side of the neck and appeared irritable. The notes reflected that the relatives insisted that the resident be transferred to hospital. The facility had not initiated any interventions regarding hospitalization prior to the family's request. The MD was called about the request of the family and ordered the resident to be sent to the hospital. Nurses Notes documented that the resident was hospitalized upon request of the family.
The pre-hospital patient record, dated 3/4/07 at 5:26 p.m., documented, "...Pt. had a large swelling to R face/neck. Swelling hot to touch, pt hot to touch. HR-110 [Heart Rate normal is 60-80]."
The admission History and Physical from the Acute hospital, dated 3/4/07, documented ". . .admitted for a few days of right neck swelling. . .. She has a lot of detritus (particle matter from wearing away of a substance). . . there is clearly a lot of dehydration, a lot of dry mucous membranes as well in the mouth." Teeth show significant caries and significant detritus within the teeth, old food stuff etc."
A history and physical, done by a consulting physician on 3/7/07, documented, "She has redness and swelling along the right side of her face extending into the neck region (previously extending into the upper central chest). . . Intraoral examination reveals varying levels of decayed teeth, with right mandibular molars and one premolar showing evidence of infection, with pus, swelling around the tooth sockets on compression of gingiva... . I believe the infection is due to her decayed and infected teeth."
On 3/9/07, a consulting plastic surgeon's progress note documented "Facial cellulitis likely due to dental carries/infection. Extraction right lower 1st molar & assoc. bridge. Findings: Debri thruout (SIC) oral cavity including 6 cm long, congealed mucus and food plug in back of throat. Right lower first molar with extensive carries. . . ."
On 3/15/07 at 9:30 a.m., the physician managing Resident 1's care at the hospital stated, "On 3/04 when I saw her, she was at risk for sudden death. She was snoring with intermittent breathing." She had a large mass at the right neck and was sent to ICU (intensive care unit) for close observation.
On 3/15/07 at 12:15 p.m., during an interview with Licensed Staff A (who worked as charge nurse on 3/1/07 -3/2/07 day shift), she stated she noted a change in the resident. The resident refused to take all (6-7) of her medications. The Licensed Staff stopped half way through the administration of the medications. She stated the resident was bearing down and opening her mouth a small amount. The resident's family member suggested the licensed staff not give all the medications. There was no documented evidence that this new behavior was reported to the physician.
On 3/15/07 at 12:40 p.m., during an interview Licensed Staff B, who worked 3/4/07 on the morning shift, as the charge nurse, stated the night nurse reported that the resident had a fever of 103 degrees F. Licensed Staff B noticed swollen red lymph nodes about 2 p.m. and called the physician.
On 3/15/07 at 1 p.m., during an interview with the Social Service Designee [SSD], she stated it was documented, on the 8/22/05 admission, that [Resident 1] had dentures. There were no dental examinations since then because the facility thought the resident had full dentures. The SSD stated "I looked in her cup and saw dentures, questioned if 'full' (dentures). My mistake. " There was no documented evidence that the facility arranged for professional dental care for this resident, from admission on 8/18/05 through 3/4/07, when the resident was hospitalized with cellulitis/septicemia due to dental caries.
On 3/15/07 at 1:25 p.m., during interview with CNA A (via interpreter) regarding Resident 1 on 3/4/07 a.m., the CNA stated, "After breakfast I put her in gerichair. More agitated, put back to bed. [Resident 1] was sweating and moaning, right neck was red a lot." The CNA stated he didn't give oral care as the resident wouldn't open her mouth. CNA A did not know if the resident had teeth, a partial or both. He stated that he did her oral care with a green swab sponge.
On 3/15/07 at 2:35 p.m., during an interview, regarding Resident 1 on 3/4/07 early a.m., CNA B stated that between 5-6 a.m., (resident's] temperature was 103 F. The resident refused oral care.
The death certificate, dated 3/13/07, documented the cause of death, on 3/12/07, as due to cardio respiratory arrest as a result of Staph Aureus septicemia for 8 days, Ludwig's Angina (an indurated cellulitis occurring in both the sublingual and submaxillary [the tongue and jaw area] spaces...usually develops from dental or periodontal infection. It may occur in association with problems caused by poor dental hygiene...Untreated it may be fatal. Merck Manual, sixteenth edition) and dental abscess for 12 days.
The facility failed to comply with the above regulations by failing to assess Resident 1 for dental status and by failing to provide routine dental services to ensure oral/dental health resulting in septicemia and cardio respiratory arrest on 3/12/07 causing the resident's death.
These violations presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result and was a direct proximate cause of the death of Resident 1.