Health inspection·July 14, 2023

The following reflects the findings of the California Department of Public Health during the investigation of: Complaint CA00838299. Representing the Department, HFEN 39111. State Citation B was written. §72301 (d) Written arrangements shall be made for obtaining all necessary diagnostic and therapeutic services prescribed by the attending physician, podiatrist, dentist, or clinical psychologist subject to the scope of licensure and the policies of the facility. If the service cannot be brought into the facility, the facility shall assist the patient in arranging for transportation to and from the service location. §483.55 Dental services. The facility must assist residents in obtaining routine and 24-hour emergency dental care. §483.55(a)(4) Must if necessary or if requested, assist the resident; (i) In making appointments; and (ii) By arranging for transportation to and from the dental services location; On 5/4/23 at 1:35 P.M., an unannounced onsite visit was conducted related to a complaint alleging dental services were not being provided to Resident 1. It was determined the facility failed to provide timely dental services and referral for outside care and treatment for one resident (Resident 1). In addition, the facility failed to provide clinical oversight of the social services department to ensure that dental services were being provided. As a result, Resident 1 had experienced tooth pain which lasted for over five months, developed infection of teeth, and was unable to eat the food she enjoyed. A review of Resident 1's Admission Record, indicated the resident had been admitted to the facility on 6/16/22 with diagnoses to include end stage heart failure and was receiving palliative care/hospice (comfort care). On 5/4/23 at 2:15 P.M., an interview was conducted with Resident 1 while inside the resident's room. Resident 1 stated she had tooth pain that had lasted for months and sometimes the pain kept her up at night and she could not sleep. Resident 1 stated, "The pain just drives you crazy." Resident 1 stated when the pain got so bad, she had one tooth pulled and it was infected, and she had to go on antibiotics. Resident 1 stated she needed to have all her remaining teeth pulled and to be fitted for dentures. Resident 1 stated when she or her family asked about getting her dental concerns addressed, the facility' s social worker (SW) 1 would tell her, "We're working on it." Resident 1 stated the facility was not following up on her dental care needs. Resident 1 further stated she had trouble chewing food because of the pain and missed being able to eat the food she enjoyed. Resident 1 stated she was tired of having soup. On 5/4/23 at 2:45 P.M., an interview was conducted with SW 1. SW 1 stated it was her job to coordinate routine and emergency dental services for the residents and to arrange and facilitate residents' dental appointments and transportation. SW 1 stated she had been working on Resident 1's dental concerns and referrals and that it had been complicated having to coordinate with hospice, different providers, and insurance issues. A review of Resident 1's clinical record was conducted. Resident 1's progress notes indicated: 10/29/22 Resident 1 complained of having a toothache. There was no documentation this was reported to the resident's physician or the facility's dentist. 11/2/22 Resident 1 complained of having a toothache. There was no documentation this was reported to the resident's physician or the facility's dentist. 11/15/22 Resident 1 complained of having a toothache. 11/16/22 Resident 1 complained of having a toothache. 1/16/23 Resident 1's daughter met with SW 1 to discuss dental surgery scheduling. The resident's daughter reported the dentist provided a referral. SW 1 asked the resident's daughter to provide a copy of the referral. 1/18/23 SW 1 informed Resident 1 that nursing was working on scheduling her appointment for hospital dental work. 1/23/23 SW 1 spoke to resident's daughter and reminded nursing to schedule appointment for (oral surgeon). 1/25/23 Licensed nurse (LN) called oral surgeon's office and was informed they did not accept Resident 1's Medicaid (a state funded program) insurance. SW 1 was notified. 2/8/23 SW 1 received call from oral surgeon's office that they do not accept Medicaid. SW 1 would follow up with Resident 1 and her family. 2/10/23 Resident 1 verbalized having a toothache. There was no documentation this was reported to the resident's physician or the facility's dentist. 2/17/23 SW 1 discussed Resident 1's dental appointment concerns with the resident's family and that the referred oral surgeon did not accept Medicaid. SW 1 and family to find a Medicaid provider. 2/25/23 Resident 1 had a toothache. There was no documentation this was reported to the resident's physician or the facility's dentist. 2/26/23 Resident 1 had a toothache. There was no documentation this was reported to the resident's physician or the facility's dentist. 2/27/23 Resident 1 had a toothache. There was no documentation this was reported to the resident's physician or the facility's dentist. 2/27/23 Resident 1 went out for a dental appointment. 3/14/23 (Hospice note) Resident 1 reported having tooth pain. 3/20/23 Resident 1 was on antibiotics for tooth infection. 3/23/23 Resident complained of tooth pain. There was no documentation this was reported to the resident's physician or the facility's dentist. 3/26/23 " ...Pt [patient] continues to report severe tooth pain." There was no documentation this was reported to the resident's physician or the facility's dentist. 4/3/23 SW 1 documented she was unaware Resident 1's family scheduled an outside dental appointment for 4/6/23. On 5/5/23 at 2:05 P.M., a joint interview and record review was conducted with LN 1. LN 1 stated she was familiar with Resident 1 and that the resident had been in her assigned section since February 2023. LN 1 stated Resident 1 frequently complained of toothache and mouth pain. LN 1 stated Resident 1 usually complained of tooth pain around lunchtime and that resident's teeth would hurt when she chewed the food. LN 1 stated Resident 1 received routine Percocet (a strong pain medication that was not prescribed for the resident's dental concerns) around lunchtime, and she did not always document when the resident complained of having tooth pain around that time because a routine pain medication was being given. LN 1 stated she did not know what to do when the resident complained about tooth pain because that was considered a dental issue. LN 1 then stated that pain was a nursing concern, and that the resident's physician should have been notified. LN 1 stated Resident 1's tooth pain was not a routine dental concern but required emergency dental care. LN 1 stated pain could indicate infection and that needed to be taken care of promptly. LN 1 reviewed Resident 1's progress notes from October 2022 through current date of interview. LN 1 stated when Resident 1 complained of having tooth pain, there was no documentation that the LN had notified the physician or facility dentist. LN 1 further stated Resident 1 had complained of tooth pain since October 2022 and, "It's been going on too long ..." LN 1 stated, "Toothaches hurt. I wouldn't want to go more than a week without having something done about it." On 5/5/23 at 11:16 A.M., a telephone interview was conducted with Resident 1's family member (FM) 1. FM 1 stated Resident 1 first complained of a toothache in October 2022 and that she had reported it to SW 1 and a LN whose name she could not recall. FM 1 stated Resident 1 frequently complained of tooth pain and that it kept her up at night and was "throbbing." FM 1 stated the family had to bring soup in for Resident 1 to eat because she could not chew regular food without having a lot of pain. FM 1 stated Resident 1 had not been able to enjoy the food she liked to eat because it would hurt when she bit down on the food. FM 1 stated it bothered her hearing how often Resident 1 was experiencing tooth pain and the "Facility's lack of action." FM 1 stated Resident 1 was not a complainer, and it was significant when the resident kept talking to her about the pain. FM 1 stated she began emailing SW 1 in November 2022 in an effort to get Resident 1's dental needs addressed. FM 1 stated Resident 1's jaw and cheek area had been swollen starting around February 2023. FM 1 stated Resident 1 had a toothache for months until the business office manager (BOM) had seen one of her emails to SW 1 in February 2023 when SW 1 was not at work. FM 1 stated the BOM made an appointment to have Resident 1 seen by a dentist in a matter of one day. FM 1 stated she did not understand why SW 1 had been unable to address Resident 1's dental needs for months. FM 1 stated she had accompanied Resident 1 on that February dental appointment where an infected tooth had been extracted. FM 1 stated Resident 1 needed all her remaining teeth extracted. FM 1 stated she had a difficult time getting the facility to assist with this. FM 1 stated due to lack of facility assistance, she had set up an outside appointment for Resident 1 to have all remaining teeth extracted (for 4/6/23). FM 1 stated when Resident 1 got to the appointment they would not see a patient in a gurney. FM 1 stated Resident 1 had to be sent back to the facility unseen by the outside provider. FM 1 stated this was "frustrating." FM 1 stated this had gone on for too long and Resident 1 should not have been in pain and discomfort like this for months. A review of email correspondence between FM 1 and SW 1 was reviewed and indicated: 11/7/22, from FM 1, " ...Can you please provide an update on when the dentist will visit [Resident 1]? She is waiting on a new partial denture and is also experiencing a lot of pain in one of her back teeth right now." 11/8/22, from SW 1, " ...The dentist will here [sic] tomorrow before 4 pm, and [Resident 1] is first on her list." 1/17/23, from FM 1, " ...The doctor for [Resident 1], said that you would schedule the appointment at the hospital for her teeth to be taken care of, and the procedure has already been approved. Is there any word on the date yet?" 2/22/23, from FM 1, " ...I have been emailing you [SW 1] since 11/7/2022 trying to get the procedure done for [Resident 1's] teeth. I just received a call from her and she stated she was up all night with a terrible toothache. It's not right that she has had this same problem for months and nothing has been done. It would be appreciated if someone at [facility name] could arrange the care she needs as soon as possible as she is in a lot of pain and has been waiting a very long time." (The BOM was included in this email) 2/23/23, from FM 1 to the BOM, " ...Aren't these arrangements for dental care for [Resident 1] a matter that the facility would take care of? I emailed [SW 1] several weeks ago and her last email indicated that she was looking into it." 2/23/23, from the BOM, " ... Usually yes, the social worker at the facility handles these ...Is any dentist that can get her in the soonest preferred?" 2/23/23, from FM 1, " ... The soonest appointment is definitely preferred. [Resident 1] should not have to be up all night with a toothache. Because the matter was not addressed four months ago when I sent the first email, it has now become urgent." 4/26/23, from FM 1, " ...I just had a 40 minute phone conversation with [state sponsored insurance]. They stated that [facility name] should have a dentist that comes in and takes care of the dental needs of long term patients ...If your onsite dentist is unable to provide the care [Resident 1] needs they are required ...to provide a referral to someone who can help ...The neglect of [Resident 1's] oral care has gone on for an unacceptable period of time." 4/26/23, from SW 1, " ...Yes the facility has an in house dentist [dentist name], she has seen and evaluated [Resident 1]. [Dentist name] also provided the referral for the hospital doctor for the tooth extractions needed which you are aware ..." 4/26/23, from FM 1, " ...I am unaware that any referral that [dentist name] may have provided 6 or more months ago. If she did so, why didn't [facility] follow up and be sure [Resident 1] got to an appointment at the hospital for the necessary treatment? Last Saturday one of her teeth actually fell out while she was eating breakfast and she is in a lot of pain every day. Full dentures need to be made for [Resident 1] and an oral surgeon located to remove all her teeth immediately. This has now become an urgent matter." On 5/5/23 at 3:30 P.M., a joint interview and record review was conducted with the director of staff development (DSD). The DSD stated a resident's pain, including mouth or dental pain, needed to be addressed right away. The DSD stated Resident 1's tooth pain could have been from infection and that was not appropriate for the social services department to manage. The DSD stated dental pain was considered an emergency dental need and nursing should have been involved. The DSD reviewed Resident 1's progress notes and stated Resident 1 should have been seen right away back in October 2022 when the resident first reported the toothache. A review of Resident 1's Dental Referral Form dated 12/1/22, indicated the facility's dentist (DDS) 1 had referred the resident to be seen and treated by an oral surgeon for extraction of all remaining upper teeth and teeth numbered 24, 19, and 18 (specific location of the teeth). The referral also indicated the resident was bedbound and required a gurney. A review of Resident 1's hospice physician's letter dated 3/16/23, indicated, " ...[Resident 1] needs dental treatment in a hospital to extract her teeth. Please work with the family to get this procedure scheduled ...." On 5/23/23 at 3:22 P.M., a telephone interview was conducted with FM 1. FM 1 stated she was unaware DDS 1 had made a referral for Resident 1 to be seen by an oral surgeon on 12/1/22. FM 1 stated they had been given the "run around" by the facility about insurance issues for Resident 1's needed dental treatment. FM 1 stated the facility did not discuss any problems with Resident 1's Medicaid that would impede the resident's access to treatment. FM 1 stated Resident 1's family had the ability to pay cash for the resident's needed dental treatment. FM 1 stated the facility did not discuss a cash option to Resident 1 and her family in order to expedite the resident's treatment. FM 1 stated the whole thing had taken too long and Resident 1 was in pain. FM 1 stated, "She [Resident 1] should be eating tacos by now," and be able to enjoy her favorite food. On 5/24/23 at 8:36 A.M., an interview was conducted with certified nursing assistant (CNA) 2. CNA 2 stated she regularly took care of Resident 1. CNA 2 stated Resident 1 complained about her teeth and mouth pain nearly every meal. CNA 2 stated she did not know how long Resident 1 had been complaining of tooth pain because it had been going on for "so long." CNA 2 stated Resident 1 would tell her that it hurt to chew and that she had to eat soup. CNA 2 stated Resident 1 was tired of eating soup. On 5/24/23 at 8:45 A.M., an interview was conducted with CNA 3. CNA 3 stated Resident 1 had complained for a long time about having tooth pain. On 5/24/23 at 8:50 A.M., a joint interview and record review was conducted with the BOM. The BOM stated he recalled being part of a bedside interdisciplinary team (IDT, different facility disciplines) meeting for Resident 1 sometime back in December 2022 or January 2023. The BOM stated during the IDT, Resident 1's family discussed the resident's dental concerns and SW 1 had told them she was working on it. The BOM stated arranging dental care, making resident dental appointments, and arranging transportation to dental appointments was managed by the social services department or SW 1. The BOM stated sometime after the IDT, he started getting added to FM 1's emails to SW 1. The BOM stated he had noticed FM 1 complaining about Resident 1's dental pain and "It was a lot of pain complaints." The BOM stated when he asked SW 1 about it, she would say she had taken care of the issue. The BOM stated