Long-Term Care Survey Alert

Nursing facilities that neglect residents oral health leave themselves wide open to survey sanctions that may have more teeth in the near future.

Not only did the Centers for Medicare & Medicaid Services train surveyors in dental health this past September, lawmakers and senior advocates continue to press for more scrutiny of this area of care.

While survey experts havent yet seen a flurry of dental deficiencies, Washington attorney Marie Infante is concerned that facilities that dont meet residents oral health needs could get hit with double citations for quality of care and neglect. Surveyors have also been told to cite dental issues resulting in unintended weight loss (F325) at an actual harm level.

"Proper resident oral health comes from a team effort between facility staff and medical and dental professionals," says Gregory Folse, dental consultant for the Louisiana Department of Health and a leader in the movement to improve dental health in nursing homes.

Folse and other geriatric experts advise facilities to take the following six steps to improve residents oral health:

1. Get up to speed on surveyor training in this area. Folse advises facility staff to watch the CMS Webcast, "Assuring Dental Health in Nursing Homes," which is available online at http:// cms.distributedclassroom.org. "After watching the broadcast, nurses should be able to fill out the minimum data set correctly and understand how surveyors are supposed to focus on oral health," says Folse, a presenter in the broadcast.

The training also helps nurses identify abnormal oral conditions. "Once you know what normal teeth, gums, soft tissue and prosthetics look like, you can fairly easily identify things like cavities, puffy gums that bleed and even some signs of oral cancer," Folse says.

2. Perform a careful assessment of the patients oral cavity. This should be done upon initial admission assessment, at quarterly care planning review and any time the resident has a change in status, including a change in dietary intake, recommends Judy Smith, a geriatric nurse practitioner and president of Clinical/Operational Innovations Corp. in Indian Hills, CO.

"The nursing staff should do a really good oral assessment because oral status affects nutrition, hydration, speech, quality of life" and can be an entry point for systemic infection, agrees Claire Hoffman, principal of Hoffman Associates in Royersford, PA. "The assessment should be done even before the nurse goes to the MDS stage."

To conduct the assessment, "ask the resident to remove his dentures and examine the gums, looking for areas where the dentures may rub," Smith advises. Also, ask the resident about any sores or painful areas in the mouth, toothache or bleeding gums. Look for leukoplakia (white adherent patches), an easily treatable, precancerous condition.

"You also look for any lumps, discoloration and nonhealing sores for immediate referral," says Smith. Its especially important to look for loose teeth, which a resident can easily aspirate into their lungs.

3. Make sure the MDS assessments match actual resident assessments and identified dental needs. Based on the recent training they received, surveyors are likely to be looking at MDS forms, comparing sections K and L (oral and dental health) to the residents observed oral condition.

To get a jump start on upcoming surveys, look to see if a patients dental resident assessment protocol was triggered and, if not, whether it would have been if the MDS assessment had been conducted and coded accurately. If the RAP was triggered, are the oral health issues addressed by the care plan? Has the care plan been implemented and re-evaluated?

4. Take a close look at the relationship between each residents nutritional status and their dental health. All residents with unexpected weight loss should be checked for dental problems, including how well they can chew and swallow, and whether they have any mouth pain or sores. Take care of ill-fitting dentures as soon as possible.

Facilities should also beware families bearing sweets. "As we grow older, our gums recede, exposing the root of the tooth which is more vulnerable to decay," explains Joseph Calabrese, director of dental medicine for the Hebrew Rehabilitation Center for Aged in Boston. "Yet a lot of times, families bring candy when they visit their relatives, which is a problem."

5. Consider prescribing a fluoride rinse for residents who have numerous cavities. For example, Calabrese says he orders a bedtime fluoride rinse for long-term care residents who have a high percentage or a growing number of caries. Calabrese tells Eli he doesnt see why a physician could not do this for residents in a facility that lacks regular access to a dentist. "There are also over-the-counter fluoride rinses," he adds, although these arent as strong.

6. Include oral hygiene as part of restorative nursing or ADL support. Task segmentation may help residents perform their oral health independently by breaking down the steps in caring for the mouth and teeth, according to the CMS surveyor training.

"To get credit for restorative care on the MDS and under the Medicare prospective payment system, the resident has to perform the activity 15 minutes a day," says Cheryl Field, director of clinical and reimbursement services for LTCQ Inc. in Bedford, MA. "[So] the facility could integrate oral hygiene into a plan to improve hygiene overall and a focus on upper extremity range of motion."