 Hello everyone, I'm Doris McMillan and welcome to the Center for Medicare and Medicaid Services Assuring Dental Health and Nursing Home Satellite and WedCast Program. The purpose of today's broadcast is to increase the awareness of the dental needs of long-term care residents, educate surveyors about the assessment of the long-term care resident's oral cavity, including normal and abnormal findings, increase surveyors' knowledge of the survey process and regulatory requirements that relate to dental services. Over the next two and a half hours, you will see and hear discussions on why you don't have to be a dentist to determine good dental care and oral hygiene for nursing home's residents. Assessing good dental care through the Resident Assessment Instrument, also known as the RAI, assessing the problem through observation, interviews, record review, and finally, under which F-tag you can write your findings on the HICFA 2567. Our presenters will include staff from CMS's regional and central offices, state survey agency and respected field expert. At the conclusion of the presentations, we will have a live Q&A session where you, the viewer, will have an opportunity to ask our speakers questions on their presentations. This broadcast is also being webcast simultaneously and can be seen up to one year following this program. First I'll give that website address at the end of this broadcast. And now that I've told you a little bit about what you can expect today and before we get into the presentations, Steve Helovitz, Director of the Survey and Certification Group, would like to welcome you to today's program. Steve? Thank you, Doris. And good afternoon and welcome to all of you. This is the first opportunity to talk to surveyors about oral health issues of residents in long-term care facilities. It's our intention to provide surveyors with useful and practical information that can be used when conducting a survey to determine compliance with federal requirements for oral health issues. As we began to develop this program, we recognized a need to address the oral health care needs of long-term care residents to ensure that they are receiving appropriate oral health care and services. The findings of the Surgeon General Report in 2000, the Healthy People Conference and the Centers for Disease Control Data support the need for improved oral health. It was noted that nursing homes and other long-term care institutions have limited capacity to deliver needed oral health services to their residents, most of whom are at increased risk for oral diseases. At any given time, 5% of Americans aged 65 and older, currently almost 1.7 million people are living in a long-term care facility where dental care may be problematic. Statutory and federal regulations require nursing facilities certified under Medicare or Medicaid or both to ensure that each resident attains and maintains the highest practicable, physical, psychological, and mental well-being. This includes oral and dental health services, which affect a person's well-being. Many participating nursing facilities are required to provide or arrange for the provision of emergency dental services and routine dental services if routine services are covered under an optional benefit in the state plan. Medicare-skilled nursing facilities must also provide routine and emergency dental services to meet the needs of each resident, but are not expected to do so without additional charge to the resident. For many nursing home residents, substantial anecdotal evidence suggests that neither dental assessments nor subsequent treatments are being provided effectively. Nursing home staff members and state surveyors who assess long-term care facilities for certification should receive appropriate training to enable them to recognize each resident's oral health needs and to ensure that necessary oral health services are available. During our time together today, we will look at oral health issues of long-term care residents and provide guidance to surveyors. Thank you for your time and attention today. Thanks, Steve. Well, let's get started with our first presentations, You Don't Have to Be a Dentist. Our presenter will be Dr. Greg Falls, a dental consultant for the Louisiana Department of Health and Hospitals. Let's hear from Dr. Falls on Why You Don't Have to Be a Dentist. I'm excited to welcome you to the first nationally broadcast training program dedicated entirely to the oral health of nursing facility residents. Never before has this issue been given such wide exposure or this level of visibility. So why are we here today? Our purpose today is to raise the awareness level of resident oral health and to give you, our surveyors, the tools you need to incorporate oral and dental health into the survey process. We're also here because for nursing facility residents, oral and dental health can be a serious and potentially life-threatening component of their overall health. As a dental consultant to surveyors in Louisiana, as a nursing facility dental director, and as a dentist who practices solely in nursing homes, I've personally seen lives saved and unfortunately, lives cut short by good versus poor oral health. My goals today are threefold. First, I want to impress upon you the serious nature of oral and dental health. Second, I want to show you the existing foundation already in place which directs us to address these issues as surveyors, nursing facilities, and healthcare providers. And last, I want to give you instruction on how to properly use this existing foundation to incorporate resident oral and dental health into the survey process. I'd like to start by taking some time to introduce you to a few friends of mine. They lived in facilities where I provided a limited amount of dental examinations and services. This is Miss Sylvia. She was the mother of the director of nurses who worked in the facility where Miss Sylvia lived. I was asked to examine Miss Sylvia's oral and dental health for the first time about eight months after she came to live in the facility. I want you to look at her dress which is clean and pressed and notice her glasses. They're also clean and her hair is properly combed. She has makeup on. The facility staff meticulously provided for Miss Sylvia's health and for her general services. There was, however, one thing they forgot, her oral health. When I looked into Miss Sylvia's mouth, this is what I saw. Her teeth hadn't been brushed for a long period of time. Her gums were bright red and inflamed. Dental infection in the form of tooth decay had started to deteriorate her teeth. It was a profound example to the facility staff, Miss Sylvia's daughter, and to me, the changes needed in the way we address the oral health needs of nursing facility residents. Next, I want you to introduce you to Mr. Joe. Mr. Joe was in the facility for over a year. Since he had a few natural teeth, I was asked by the staff to take a look at him. He was a grumpy old man and would wheel around in the nursing facility with his head down and he was ornery. His life seemed void of hope. When I first saw Joe, I realized something wasn't right. His lower lip seemed to protrude too much. As you can see on the slide, when I lifted his lower lip to look under and see what was there, I found this. There was a large basal cell carcinoma under his lip. Fortunately, we were able to arrange radiation therapy and this tumor went away, not to return. I also saw that Mr. Joe's teeth hadn't been brushed for a long time. Had daily oral care been provided, I'd know in my heart that someone would have found this cancer. With his recovery, Mr. Joe's outlook on life changed completely. He now had a hope and quality of his life improved. He became an active member of the facility and enjoyed the rest of his days. So I ask you, does oral health have a significant impact on residents' lives? This next slide may be a little hard to see, but it makes a significant point. It's a chest x-ray of a resident who had loose teeth previously noted in his chart. The loose teeth weren't, unfortunately, treated or removed. One day, the resident rolled over in his bed, hit his mouth on the bed rail, knocked out a tooth, and then inhaled the tooth into his lung. You can see on the chest x-ray that the tooth is sitting in the patient's lung. After a major surgery under general anesthesia, the resident's tooth was surgically removed. Unfortunately, the quality of this resident's life had been significantly compromised by a surgical procedure that was avoidable. As my last example of how important oral health is to residents, I want to introduce you to Ms. Mary. I was called to a facility to see Ms. Mary because as the staff told me, Ms. Mary couldn't eat and they suspected that she might be having problems with her teeth. Two weeks before I took these photographs, I want you to know that Ms. Mary had no outward appearance of problems. She does have a large birthmark on her face, but don't be concerned with that. When I first saw Ms. Mary, she was delirious. She couldn't focus or speak, her head hung down, and she had problems cooperating with my instructions. Also in this slide, notice how her face was swollen, which caused her nose to deviate to the side. When I first saw her, I also noticed that because her head hung down, she had some purulent drainage visible on her bib. I immediately suspected a serious dental infection. When I looked into her mouth, what I saw was much worse than I anticipated. Ms. Mary had a huge tumor growing in the front of her mouth. The tumor was about the size of a large egg. As you can see, this is how I found Ms. Mary. The tumor was large, had become infected, and Ms. Mary was septic. This tumor could not be missed when looking in her mouth. I also noticed the heavy plaque build up on her teeth, which you can also see on her slides. Had her teeth been brushed recently, most of the plaque would have come off. It was clear that oral care had not been provided for some time. I immediately put her on antibiotics, called her physician, and an oral surgeon who planned a surgery to remove the tumor after the infection was controlled. Unfortunately, one week after I saw her, Ms. Mary passed away due to complications from her condition. I was really disturbed by her death. Had Ms. Mary's teeth been brushed routinely, someone would have seen the egg-sized tumor growing in the front of her mouth. And hopefully, she would have received treatment. Some months later, I gave a training session on oral health to the surveyors in my state. And as I was telling Ms. Mary's story, a humble and visibly upset surveyor stood up and told a large group that Ms. Mary was a phase one resident in a survey that she had been in charge of. And Ms. Mary was one of her residents. Very quietly, she said, and I missed it. I didn't look in Ms. Mary's mouth. She understood that had she looked, the outcome of Ms. Mary's tumor might have been very different. My personal and professional reason for being here today is to ensure that there are no more Ms. Mary's out there. I'm here today to impress upon you that as surveyors, nursing facilities, staff, and staff working in other health care settings and health care providers, we must consider oral health an integral part of the body and the overall health of every resident. In our survey of resident health, we must afford oral and dental health a position equal to all other health issues, no more and no less. The question I pose to you is, have you helped all the Ms. Mary's whom you've assessed? If you can't answer yes, my goal today is to help you become comfortable with and knowledgeable about assessing and surveying oral health and dental health issues in nursing facility residents. After this program, I hope you view unassessed and untreated oral disease as what I call a lip-hidden bed sore. Although we must include the mouth as part of the body and part of the survey process, I've found many facility staff members and surveyors to be more comfortable observing a pressure sore in a resident than looking in a resident's mouth. As a team, we need to develop a high comfort level of looking inside a resident's mouth. Pain, infection, and problems from poor oral health can really complicate or even cause serious medical conditions. In the literature, including last year's Surgeon General's report entitled Oral Health in America, there are demonstrated connections between poor oral health and systemic diseases such as diabetes, stroke, pneumonia, heart attacks, unexplained recurrent infection, recent cognitive loss, infective endocarditis, which is usually deadly, and a history of rheumatic fever. Think about it. If we give bacteria an open root into the bloodstream or lungs, which oral disease quite often does, it's easy to see how these health conditions may be further compromised by poor oral health. More specifically, a resident with an aspiration problem, oral hygiene is critical. If the teeth or the dentures are covered with plaque, which is mostly bacteria, I guarantee you that oral bacteria will wind up in their lungs and a pneumonia can develop. Additionally, a diabetic resident with severe gum disease, which is a chronic infection, can have great difficulty regulating their sugar levels. Removing the source of infection can improve their diabetic condition. Infection from oral bacteria is just one of the ways that poor oral health influences general health. A stroke can make a resident's face sag because their facial muscles stop contracting. This stroke complication can ruin the function of a good set of dentures. With new dentures made a little differently or even adjusting the old dentures, a dentist can sometimes restore chewing function for a resident. If you want to learn more about the ways oral health can affect general health, I've provided a list of references that you can download that contains articles that discuss the adverse effects of poor oral health on general health conditions. The good news is that you don't have to be a dentist to assess or survey resident's oral and dental health. To do this efficiently, I recommend that you focus on the difference between normal and abnormal oral health. There are four major components of oral health that I want you to consider, the teeth, the gums, the soft tissue, and the appliances a resident may have such as dentures or partials. Let's begin by looking at these structures in a normal, healthy mouth and then compare them to abnormal or disease structures. These are normal teeth with some old silver fillings. Notice that they're solid and there are no broken areas and you can see a glassy kind of glow to them. The dark silver fillings are normal and intact. Specifically, nothing looks abnormal. While we're looking at healthy teeth, I'll draw your attention to this resident's gums. These are normal healthy gums. Notice how light and pink they are. There are no bright red irritated areas nor signs of infection or swelling. Here are some more healthy teeth and gums. These, in contrast, are teeth with dental decay or in common terms cavities. Look at the dark color of the cavity. As you can easily see, this is not normal. These are broken teeth, commonly called root tips. Teeth can be broken like this by fall or from chewing forces if the teeth are weakened by decay. Also look at the gums around these teeth. They are infected. Notice the bright red color, the inflammation, and that the gums are bleeding around the root tips. This is a sign of trouble. Loose teeth are also an indication of severe gum disease. I'd like to show you a quick video to detail loose teeth. Notice on the video that I've asked a staff member to test the teeth and see if they're loose. She's touching the teeth now and moving them back and forth. As you can see, these teeth are loose and not normal. Moving on, let's discuss the soft tissues of the mouth. The soft tissues include the palate, the cheeks, the gums, the lips, and the tongue. When you're looking at soft tissue, think of two things, shape and color changes. Specifically, does the shape of the palate, cheeks, the gums, the lips, and the tongue look normal or abnormal? Are any of those structures swollen, enlarged, malformed, have any abnormal growths? For color changes, ask yourself, does this color look normal? Simply, most abnormal colors will be red, white, or blue. If you can consider those colors, you'll do well. More specifically, abnormally red and white areas can indicate infections, irritations, growths, and ulcers. Blue or bluish discolorations are rare, but can indicate abnormal growths or bruising from various sources such as a recent fall or other trauma. This resident who has teeth has normal soft tissues. Look at the pink color. There are no red, white, or blue areas that stand out as a potential problem. This resident has no teeth, but her upper jaw, more commonly called the upper ridge, has normal healthy soft tissue. Again, there are no red, white, or blue areas that stand out as a potential problem. This is the same resident's lower ridge. We see no areas of white, red, or blue indicating that her soft tissue is normal. Ah, but I bet you noticed the root tip on the front of her ridge. Very good. I told you that you don't have to be a dentist to help residents with their oral health. This next slide shows abnormal soft tissue. Notice the redness of the resident's palate, and compare it to the normal, healthy pink color of the back of their palate. Here's a resident with a white patch on her tongue, which is not normal. This condition, a yeast infection, is easily treated. These patches usually form on the tongue, palate, or the cheeks. I see this condition common in many residents. A resident with this condition, or type of infection, would need to see a dentist and or their physician for appropriate medication and treatment. Use your instincts and your common sense to question different tissue types. If it doesn't look right to you, it probably isn't right, and needs evaluation and an intervention by a dentist or a physician. This is oral cancer on a resident's palate. Again, it is not difficult to see that this is an abnormal tissue. Moving on to dentures. When assessing or surveying a resident, you want to notice whether their dentures are staying in place while they talk or eat. These are normal dentures. Notice that they are clean, not broken, and all of the teeth are in place. In contrast, these dentures are dirty and have broken teeth, and are so old that a hole has worn through the plastic. These old dentures can, but don't always, cause problems for a resident. This is a partial denture, often called a partial, being used for brushing demonstration. Ideally, even only for demonstration purposes, gloves should be used when handling partials or dentures. A partial replaces just a few teeth in a resident's mouth, attaching to natural teeth, and provides function where teeth have been lost. Notice that the partial is intact as all the teeth are present. If a partial has missing teeth, or the resident has other obvious problems with it, further investigation is warranted. I'd like to discuss oral hygiene with you. This person has very good oral hygiene. Notice that the teeth and gums are clean, there's no buildup of any kind on the teeth or the tissue. If you notice recent food particles, and the resident has just eaten, that's OK. Long-term, soft buildup, like we saw earlier on Miss Mary's teeth, is called plaque, and is not OK. Plaque usually can be brushed off, and Miss Mary obviously had poor oral hygiene that needed intervention to remove the plaque. In contrast to soft buildup, this is hard buildup, sometimes called tartar, or calculus. This will not brush off, and can only be removed by a dental health professional. Plaque and calculus are the cause of tooth decay and gum infections. Dentures are also affected by poor oral hygiene, and both plaque and calculus can be found on improperly cleaned dentures and partials. When not cleaned properly, dentures or partials can be a harmful source of bacteria and yeast for nursing facility residents, especially for those who are medically compromised. For oral hygiene, I have a basic rule of thumb. Oral hygiene should be provided to every resident every morning, and every resident every evening. So once during the morning shift, and once during the evening shift, oral hygiene should be provided to or offered to all residents, including tube-fed residents, cognitively impaired residents, NPO residents, and medically compromised residents. The survey of focus, however, should be on the outcome. Is the resident's oral hygiene acceptable? Proper techniques for providing oral hygiene to a resident include brushing the natural teeth and gums and the tongue, and removing and brushing dentures and partials while making sure to clean the mouth properly after their removal. For a resident with a partial, a staff member needs to brush not only the partial, but also the teeth that the partial is connected to. At night, it's best for dentures and partials to be removed, cleaned, and placed in a clean denture cup with fresh water to soak overnight. But for many residents that are used to sleeping with their prosthetic in their mouth, removal is not advised as it can cause problems for the resident. An alternative time should be found to clean these appliances of these residents. Oral hygiene services also include performing any oral hygiene regimen prescribed by a dentist. For example, a dentist may prescribe fluoride treatments for a resident, and these treatments must be provided according to his or her prescription. Before we get specific on survey issues, I want to share some significant national data with you. As you know, the minimum data set, or the MDS, is a comprehensive resident assessment form that nursing facilities are required to complete for every resident. The full MDS assessment form, version 2.0, must be completed upon admission, upon a significant change in resident health, and annually. Oral and dental items can be found on the full MDS form in both the oral nutritional status section and the oral dental status section. In contrast, the shorter quarterly MDS form contains no specific oral or dental items. When completing the full MDS form, nursing facilities are required by federal regulation to properly assess each resident and properly code each item. More specifically, when a resident has a loose tooth, the loose tooth item should be checked or coded on the MDS. The codes generated are reported electronically by each facility to CMS. I want to present to you some national prevalence data for the dental related items. These data were obtained from CMS and came from 3.6 million MDSs completed by facility staffs across the country from September of 1998 to December of 1999. To better analyze these data, another dentist and I reviewed the charts of 500 nursing facility residents and coded the same MDS items. When comparing what we saw to the nationally reported MDS data, we found extreme differences. For example, our smaller study found 32 to 34 percent of residents to have broken, loose, or decayed teeth. The national data, however, showed only 3.8 percent of residents to have these conditions. We found roughly 40 percent of residents to have gum disease, oral abscesses, ulcers, or rashes, or the national data showed only 0.8 percent of these residents to have these conditions. 0.8 percent is an extremely low prevalence of gum disease alone, much less all of the conditions combined. 0.8 is also far lower than the prevalence of gum disease we find in healthy adults across the United States. These comparisons indicate that a significant problem in the resident assessment process for oral health across the country is present. Comparing this problem, compounding this problem, the Alzheimer's Association reports that over half of nursing facility residents suffer from Alzheimer's disease or a related disorder. For residents who can't speak for themselves, our most vulnerable residents facility surveyors must assure that residents get proper oral health assessments by nursing facilities. I've provided for you a handout entitled MDS Data Table, which details these national data, our comparison data, comparison data from the literature, as well as a handout called Individual State MDS Data. I've also included my contact information. Feel free to contact me with any questions. I look forward to continuing our discussion in a few minutes. At that time, I'll give you the what, when, and how to include oral health into the survey process, complete with sample questions to ask residents and facility staff. We'll also discuss the clinical ramifications of the existing regulations on resident oral health. I'd like to turn the presentation over to you to our next presenters, who will discuss the MDS and the RAP specifics for oral health. Thanks, Dr. Falls. Next, we're going to hear a prerecorded presentation from Sue Swalina, a health quality review specialist from CMS's Regional Office in Chicago, and Kathy Posek, also a health quality review specialist from CMS's Regional Office in Kansas City, on assessing the process through RAI. Our goal is to increase survey or comfort in assessing the oral health of residents in long-term care facilities. Sue Swalina and I will review assessment parameters using the resident assessment instrument, of which most of you should be familiar. We will provide guidance for reviewing and validating the facilities assessment of the resident's oral health during the long-term care survey process. The resident assessment instrument, which I will refer to as the RAI, consists of the minimum data set, the MDS, and the resident assessment protocol, the RAP, as well as the utilization guidelines. As surveyors, it is likely that you routinely check the condition of a resident's skin. Assessing the condition of the resident's mouth is of equal importance, though it is often overlooked. I challenge you to focus on observations of the resident's oral health until it becomes second nature to you, much as shaking a resident's hand, when you greet them. Look at the mouth assessing the condition of her lips, tongue, and teeth as you converse with them. Observe for odors, dry cracked lips, and the presence of, as well as condition of their teeth. This is a first observation or a first impression. During the survey, there are findings or survey focus areas that will prompt the surveyor to review the oral dental sections of the MDS. Many of the concern areas identified on the roster sample matrix, also known as HICFA Form 802, would leave the surveyor to review the resident's oral dental status. Your packet contains a copy of the HICFA Form 802, the roster sample matrix. During offsite preparation, the survey team identifies concern areas to focus observation during the survey. While on site, the survey team reviews the selected focus areas and considers new concerns identified on site. During the survey, the focus areas guide resident care review, a number of the focus areas on the roster sample matrix would lead the surveyor to review the resident's oral and dental health. Let's consider some of the focus areas. Privacy dignity issues are the first focus area on the roster sample matrix. Observe for stained, broken, or carious teeth or lack of teeth. These conditions may be dignity issues for the resident. It is not at all rare for some residents to be embarrassed by the way their teeth look. If this were the case, the resident might shy away from the social contact in the facility or withdraw from communication with staff and other residents. Some residents may wish to have privacy when staff provides or assists with oral care. You could ask the resident how they feel about the current status of their teeth. In the case of the edentulous resident, does being edentulous negatively affect self-image? The next focus area is social services. Residents may need assistance to replace lost or broken dentures or to obtain preventative dental care or treatment for identified conditions. When needed, are social services involved in assisting the resident or family to schedule the appointment or arrange transportation? Consider the focus area choices. How is oral care provided for the resident? Has the facility identified the resident's usual and customary oral practices? Are residents included in planning when and how oral care is to be provided? Neglect is another focus area that may trigger review of the resident's oral dental status. Is there evidence that adequate oral care is provided? Are there untreated oral conditions? Has an identified problem gone untreated for a significantly long period to warrant concern that the problem is not being addressed by the facility? When focusing on a home-like environment, look to see if oral care equipment is readily available in the resident's room. What condition is it in? When the resident has a history of falls, review the record to see if the facility has assessed the resident for loose or broken teeth as a result of the fall. When you are focusing on behavioral symptoms, depression, observe the resident during oral care. Does the resident resist oral care? Has the resident lost interest in providing their oral hygiene? When the focus is nine or more meds, review the medications taken by the resident for medications that decrease salivation or affect taste sensation. Anihistamines, antipsychotics, and diuretics would be examples of medications that can cause dry mouth. Dry mouth is a very common complication of the use of multiple medications. Consider the focus area of cognitive impairment. Memory loss can result in the resident forgetting to do their oral hygiene. Is the facility monitoring how well residents provide their own oral care? When thinking processes are altered, the resident may not be able to tell staff they are having mouth pain. If you are focusing on weight, nutrition, swallowing, or dentures, you will already be monitoring for weight loss or poor nutritional status. Consider oral conditions that may cause inadequate nutrition, such as difficulty chewing foods because of poorly fitting dentures, loose or broken teeth, altered taste, sensitivity of teeth to extreme temperatures, and mouth pain. Additionally, weight loss can result in poorly fitting or loose dentures. Poor nutrition may lead to mouth sores. A resident's ability to care for their own teeth or staff provision of oral care should be reviewed when focusing on the concern areas of bed fast, ADL decline, physical restraint, mental retardation or mental illness and hospice. Residents who previously provided their own oral hygiene may no longer be able to do so or provide adequate oral care without assistance. How has the facility assessed and planned for this? The resident who is physically restrained may now require assistance with oral care. Residents can have a resulting decline in ability to care for self. As the resident's condition declines at the end of life, there may be a loss of interest in hygiene or loss of independence in self-care. When focusing on tube feedings, observe when and how oral care is provided. A resident who receives non-oral feedings will continue to require oral care even if they are not eating. The effects of decreased salivation should be considered when reviewing the focus areas of dehydration, psychoactive medications, oxygen, and respiratory. Oral dental concern should be considered when focusing on the concern area for pain and comfort. Does the pain and discomfort relate to the mouth or affect the resident's ability to care for themselves? Finally, when reviewing the focus area for language communication, the resident may not be able to communicate presence of mouth pain or discomfort. When possible oral dental concerns are identified, the surveyors should review the resident's documented assessment on the resident's MDS at sections K and L, which are specific to the oral and dental assessment. I will be referring to the full MDS assessment form, version 2.0. You will find a copy of this comprehensive assessment in your handouts. Consider section K and L of the MDS. Section K relates to oral nutritional status, and section L relates to oral dental status. In section K, oral nutrition status, item number 1, ask the reviewer to consider if the resident has any documented oral problems. At small letter A, does the resident have a chewing problem? Can they chew the foods provided? Observe the resident at mealtime. Are residents leaving meat or other difficult to chew foods uneaten? At small letter B, does the resident have a swallowing problem? Do they cough as they eat? Does the resident have a recent or past history of stroke? At small letter C, is there evidence the resident may be experiencing mouth pain? Do they grimace when chewing, eat only on one side of the mouth, avoid hot or cold drinks? In the same section, at item number 4, review the identified nutritional problems. At small letter A, does the resident complain about the taste of more than a few foods? Could the resident's ability to taste foods be altered by medications they take? Does the resident have dry mouth or dehydration, which can affect the taste of the food? At small letter C, does the resident leave 25% or more of food uneaten at most meals? Consider if the resident has adequate time to eat the meal and receive queuing when needed. Are foods served that the resident enjoys in a form they can eat? At section L, oral dental status, consider the documented assessment data. The first part, item number 1, identifies the resident's oral status and disease prevention. At small letter A, does the resident have debris described as soft, easily removable substances present in their mouth prior to going to bed at night? During the survey, it is not always possible to assess the resident's oral status at bedtime. However, surveyors should observe for mouth debris at other times during the survey. Consider when the resident last ate. What is the facility practice for providing oral care? At small letter B, does the resident have dentures or removable bridge? Consider how well the dentures fit the resident. This observation can be made while talking with a resident or observing them while eating. An alert resident may be able to tell you if their teeth slip while they talk or eat. At small letter C, does the resident have some or all natural teeth lost? Does the resident have dentures or a partial plate? And do they use them when eating or conversing? At small letter D, does the resident have broken, loose, or carious teeth? An alert resident could respond to this question by the surveyor for cognitively impaired residents and when the resident is unsure or unreliable an oral inspection of the mouth would be necessary to answer this question. Dr. Fulce will discuss this more a little later. At small letter E, are any of these conditions present? Inflamed gums, swollen or bleeding gums, oral abscesses, ulcers, or rashes? While it is not critical that a specific disease entity or condition be diagnosed, it is important to identify abnormal conditions. At small letter F, daily cleaning of teeth and dentures or daily mouth care by residents or staff. How is the resident's daily oral hygiene accomplished? If the resident is interviewable, ask if they have had their teeth cleaned. Observe the provision of personal care. Oral hygiene is commonly provided during morning care, following meals, or at bedtime. But of course it can be provided at any time of the resident's choosing. If following phase one sample observation, oral care has not been observed, then ask staff when oral care is commonly provided. Review the facility policy and procedure for oral care. Following review of sections K and L of the MDS, the surveyor could validate the facilities assessment through their observation, interview, and record review during the survey. If you have concerns, you may want to explore the process the facility uses to complete the MDS. You could ask who on the facility staff completes the dental section of the MDS. How does the facility collect the assessment information to complete sections K and L? When the facility identifies a resident with dental or oral problems, how do they proceed? The next step in the RAI process is review of the trigger legend. Sue Swalina will discuss this next step. Thanks, Kathy. Next, Sue Swalina will continue this discussion on assessing the process through RAI. But before we hear from Sue, I'd like to give you the phone and fax numbers that you'll need to talk to our panel. To ask questions of our panel, the number to call is 1-800-953-2233. If you'd like to fax in your questions, the number is area code 410-786-1424. All right, let's hear from Sue now. Hi, I'm Sue. I, too, am a registered nurse. I want to consider with you the facility's obligations once the MDS has been completed. During your review of the MDS, it is important that you have noted those MDS areas that would indicate that the facility should be comprehensively assessing the resident's oral or dental condition or should have worked the dental care wrap. You may want to refer to the trigger legend form in your handout. The trigger legend identifies which MDS codes would indicate that the facility should have reviewed the dental care wrap. Let's look at what codes would trigger a dental wrap. If you look at your trigger legend, you will note that the upper left-hand corner has the key for interpreting the symbols in the column under the titles of each of the wraps. If you follow down the column for the dental care wrap, you will note the first time the wrap is triggered is when the MDS has a check mark in the section K1C indicating the resident has mouth pain. There are three solid black circles in the dental wrap column. If you look back at the column for the MDS items corresponding to the circles under the dental care wrap, you will see that there are only six MDS elements which trigger a dental care wrap review. It is important to note that it only takes one of the conditions coded in the MDS items to trigger a wrap. Some facilities will place a trigger legend form in the record along with the MDS and wrap summary and will circle or highlight the items that have triggered a wrap, but the facilities are not required to keep a copy of the trigger legend in the record. The dental care wrap provides a structured, problem-oriented framework for organizing and collecting additional information about each resident's dental health and about dental problems that may require immediate attention. The wrap also helps organize the MDS information about confounding problems pertinent to the resident's dental status. A copy of the dental wrap is included in your handouts. If you look at the dental care wrap, you will note that the wrap provides an introductory overview of the importance of the dental status and some risks associated with poor oral and dental status. The first trigger considered in the discussion of the wrap is the coding of L1A on the MDS. Let's consider section L on the MDS for oral dental status. Section L1 addresses oral status and disease prevention. If L1A debris, food and plaque is checked to indicate it is present, the wrap is triggered. This debris may be food or bacteria-laden plaque that causes odor and begins to decay teeth. The facility should have identified or described which factors may be inhibiting the resident from adequately removing the oral debris. When L1F, daily cleaning of dentures or teeth is not checked indicating the resident does not get daily cleaning of their teeth or dentures, then further investigation by the staff was indicated. Let's consider section K, oral nutritional status on the MDS. If K1C mouth pain is coded, further assessment was warranted. Was the mouth pain temporary? Was there recent dental work that might have addressed the problem? Was it ill-fitting dentures, canker sores? Did the facility address the pain such as through the use of pain medications or through referral to a dental provider? If L1C is checked indicating some or all of the resident's natural teeth are lost or the resident does not have or does not use dentures or partial plates, then the facility should have included this information in the overall evaluation of the resident's oral, health, dental and nutritional status. If the resident has missing teeth but no dentures or doesn't use the dentures that he or she does have, the staff should have investigated. We would expect that staff would have noted whether the resident has ever been fitted for dentures, whether a referral to the dentist is pending, why the resident is not using his dentures or doesn't have them. Perhaps this would consist of a note that the issue was discussed with the resident or that a referral was made to a dentist. Recently, during an interview with the resident and her husband, who was also a resident, I discovered that the facility had made arrangements for her upper plate to be repaired so she wasn't using her upper denture. Her MDS indicated that she had an upper plate but it did not indicate that she was not using her dentures. This was not an MDS error in coding because it was an acute event and the facility had taken action to be sure the denture was repaired. Additionally, the care plan did not require any changes regarding her dentures because it was a short-term issue already being resolved. Consider what I would have needed to do if the facility had not been taking action to respond to this resident's broken dentures and if L1B indicated that the resident had dentures and L1C had been left blank, indicating that the resident was using her dentures. I would have needed to follow up with the resident and the staff to determine if this was a recent change in condition or a long-standing problem, why action had not been taken and whether the MDS was correctly coded. Further assessment would also be indicated if L1D, broken, loose, or curious teeth is checked or if L1E indicates the resident had inflamed, swollen or bleeding gums, oral abscesses, ulcers, or rashes. If the MDS has indicated that any of these conditions is present, the facility should have completed the dental care wrap. As we've said, the structure of the wrap is to help the staff examine pertinent assessment data from the MDS and to facilitate review of additional clinical information. The wrap guidelines identify confounding problems that would cause or prevent the resident from adequately removing oral debris. These confounding problems could be impaired cognitive skills, impaired ability to understand, impaired vision, impaired personal hygiene, resist ADL assistance, motivation and knowledge of a resident who is independent in oral dental care but still has debris or performs care less than daily, adaptive equipment for oral hygiene, dry mouth from dehydration or medications. You may have noted that many of these confounding problems are areas of concern or resident characteristics identified on the HICFA Form 802, the roster sample matrix that Kathy described earlier. Whenever a resident who has been selected for the sample has any of these confounding problems, we should be alert to the potential for oral or dental status problems, whether or not the dental care wrap has been formerly triggered. Let's review the confounding problems. If the resident has impaired cognition, have the staff determined whether the resident needs just queuing or reminders or needs step-by-step direction? Does the resident need reminders to clean his or her dentures? Does he remember the steps necessary to complete oral hygiene? Would he benefit from supervision or task segmentation where each step of the task is broken out, for example, with denture care? The resident is instructed. Step one, get his denture cup. Step two, get his denture cleanser. Step three, remove the dentures from his mouth. Step four, put his dentures into the cup. Step five, go to the sink. Step six, turn on the water. Step seven, put water in the denture cup and, step eight, put a cleansing tablet in the cup and so forth. If the resident has impaired ability to understand, have the staff evaluated the extent of the impairment? Can the resident follow verbal directions or demonstrations from mouth care? Does he or she know what to do when handed a toothbrush and toothpaste or when placed at the bathroom sink? If the resident has language difficulties, has the facility developed an approach to communicate with the resident? If the resident has impaired vision, have the staff determined whether the resident's vision is adequate for performing mouth care? Does the resident need his glasses on to be able to do this? Determine the adequacy of the resident's personal hygiene. Did the resident receive supervision or assistance with oral dental care during the last seven days? Has the facility assessed the resident to see if he or she could do it independently? Does the resident have partial or total loss of voluntary arm movement or impaired hand dexterity that interferes with self-care? What would the resident need to be more independent? If either the MDS or staff indicates that the resident-resist ADL assistance have the staff looked for causes, does the resident resist mouth care? If so, why? For example, would the resident prefer to do his or her own oral care? Is the resident having mouth pain? Is the resident apathetic or depressed? Is the resident motivated to care for his or her own teeth or has the resident never cared for his teeth and mouth? How does the resident perceive the approach of staff? Is the resistance related to specific staff? Does the resident display fear or astartal reflex or is shying away from a particular stimulus or from an unfamiliar voice or surrounding? If the resident has debris or performs care less than daily, has the facility assessed the motivation and knowledge of the resident who is independent in oral or dental care is the resident brushing adequately? Does he or she know that it is most important to brush near the gunline? Does he or she need to be shown how or be given reinforcement for maintaining good hygiene? Has the facility assessed whether the resident needs adaptive equipment for oral hygiene? Has the resident tried or would he or she benefit from using a built up, long handled or electric toothbrush or suction brush for cleaning the teeth? If the resident has dentures, does the resident have denture cleaning devices such as a denture brush or equipment and supplies to soak dentures? During the initial facility tour, observation of resident rooms and resident review, the surveyor may be able to determine whether any of the residents have supplies for oral care or have any adaptive equipment. If the surveyor notes that the resident is at risk for dry mouth or dehydration, has the facility evaluated this risk in relation to the resident's oral and dental health? Have they considered the impact of the resident's medications and the adequacy of the resident's fluid intake? It is important to compare the facility's assessment of the resident to the information you've gathered during the survey. What information did you obtain during your observations and interviews? What did the facility find on assessment? Does it match the information you've obtained? If it does not, did the facility miss something? Did the nurse aid staff notice any change in the resident's condition? Has the nurse aid staff advised the charge nurse? Has the charge nurse responded to the nurse aid's concern and evaluated the resident's status? Compare the comprehensive assessment to the quarterly assessments. Were there any differences? Did the resident's status improve or did it deteriorate? Even if there are differences between the full and quarterly assessments, have the difference of the differences may not have required a significant change in assessment, in which case the reps are not worked. Regardless of the facility's determination about whether the resident experienced a significant change, the facility is not relieved of its responsibility to thoroughly evaluate and monitor the condition of the resident and to establish or modify the care plan as appropriate. Let's consider some examples. In this example, the resident's MDS at Section G indicates she is independent in personal hygiene, including oral hygiene. You observe the resident to have plaque and food debris between her teeth and the resident has a mouth odor. If you notice this debris just before the resident is going to bed or has just gotten up, this may indicate that there is a care problem. But if you observed the debris and the resident had just eaten lunch, you would follow up to see if the debris gets removed. This observation of debris should prompt the surveyor to review Section L of the MDS. If L1F has a check mark to indicate the resident receives or does daily cleaning of her teeth, the dental care wrap and further evaluation of the resident's oral health would not be triggered. L1F only triggers a wrap review when there is no check mark at L1F. If your observations reveal that debris is present every time you observe the resident, you will need to query staff about the change in the resident's oral status or about the accuracy of the MDS. In addition, you would determine the adequacy of the oral care being provided either by the staff or the resident herself. Consider another example. You are observing a resident with Parkinson's disease for ADL concerns. You notice that the resident does not have the dexterity to brush his own teeth. You observe him to have plaque and food debris between his teeth each of the four days of the survey. On interview, a direct care staff member states that staff brush the resident's teeth for him. Section G of the MDS indicates the resident requires only supervision for oral hygiene. The surveyor is prompted by these findings to review Section L of the MDS. In this example, L1B is coded to indicate that the resident has dentures or a removable bridge and L1F is coded to indicate the resident receives or does daily cleaning of his teeth. Again, this does not trigger a wrap review. The surveyor is concerned about the accuracy of the MDS data because the coding information does not match the surveyor's observation of the resident. The surveyor would then compare the resident's full assessment to the quarterly assessments. Were there any differences? If one or more quarterly assessments are more recent than the full assessment, did they indicate a decline in the resident's ability to do oral hygiene? Are the MDSs inaccurate or has the resident had a change of condition? Is there an existing problem that has been overlooked? These are some of the questions the surveyor answers as he or she works through the survey process. The surveyor must also consider whether the facility is focusing only on existing problems or whether the facility has identified the potential for improvement. For example, have the staff assessed a resident who has had a recent CBA and now has a self-care deficit? Have the staff determined if the resident can do any or all of his or her own oral care or if the resident would benefit from a supervised task segmentation plan? If the resident has a potential for improving his ability to do his own oral care, have the staff implemented measures to assist the resident to reach his highest practicable level of functioning? Is the resident able to adequately care for his or her own teeth or dentures? If the resident is unable to do self-oral care, is the facility providing the care needed? Look for evidence of assessments by the facility. How is the facility looking at the assessment information? Are they considering the MDS elements as separate pieces of information or are they tying them together and analyzing the resident's status comprehensively? Is the decision to proceed or not to care plan made appropriately? Even if the staff accurately determined that there was not a current problem with oral hygiene or dental status and that the dental care rep was not triggered, the staff may determine that there are confounding problems which could affect the resident's dental status. In that case, the staff may choose to care plan for a potential change in ability or to prevent a potential negative outcome. As surveyors, we should keep in mind the impact that the confounding problems described in the RAP guidelines may have upon a resident's oral and dental health. Because the mouth plays such an important role in the resident's overall sense of well-being, self-perception and nutrition, the oral and dental status of the resident is of crucial importance to the surveyor. Thanks, Sue. Well, that concludes the first part of our broadcast. Before we go to the second half of our program, let's take a few calls from our viewers. To ask questions of our panel, the number to call is 1-800-953-2233. And to fax in your questions, the number is area code 410-786-1424. And while we're waiting for you all to call in, let me ask Dr. Falls a question. Now, do I understand you correctly that you're not looking for surveyors and facility staff to diagnose specific dental diseases and conditions? Exactly. There's so many diseases and conditions to take into consideration that it would be very difficult to teach all of those at one time. By looking at the conditions in a normal versus abnormal way, that's the best way to determine what's going on. Use your common sense. Anything that you see that doesn't look right probably isn't right and needs a dental referral of some kind. At least it begs the question to be asked. Correct, exactly. All right, let's see. When would a dental condition result in a significant change MDS? Sue, would that be for you? Well, let's take a look at the definition of significant change. You need to know that there would perhaps be two or more areas where a resident would decline or where a resident has improvement. So let's look at if there's a decline and let's look at dental care. What's happening with their oral dental status? Is there pain? Well, if there is pain, how is this affecting the resident? Is there been a change in their ADLs? So you would look at these sorts of things and you would then make that determination, is it going to be permanent or is it just going to be a short term? Is something going on with the resident? So once you've made the determination that this is going to be long lasting, then you would look at your MDS see how it already has been coded. If not, you would look further into how come a significant change had not been looked into and followed through with the facility. Okay, thanks a lot, Sue. Let's take a telephone call. We have Jessica on the line calling from Chatham, Alabama. Jessica, thank you for calling. Please go ahead with your question. Yes, my question is, when a resident has teeth that need to be removed either by an oral surgeon or a dentist and the resident has no family to pay for the services, is the nursing home responsible for paying for those services? Would like to take that. That's a regulatory question which we're going to get into a little bit more at the end of the broadcast today. There are some specific wordings in the regulations under 411 and 412 that address that issue and again, we'll get to them more a little later today. All right, Jessica, so you make sure you call us back when we get to the second part of our program and ask that question again. Is there a deficient practice when a resident chooses not to brush their teeth as frequently or in the recommended manner for oral health practices? Kathy, could you take that? Yes. A resident has the right to choose not to brush their teeth every day. It's a resident's choice. Now if the facility would determine that it is the resident's choice not to brush every day or as often as recommended, then they would need to inform the resident of what possible negative outcomes there could be, such as cavities, gum disease, tooth. And so the thing that the facility would want to do would be to document what they've done, what they've told the resident. So there's absolutely no way that you can make them take care of their oral health. We respect the right of the resident to choose for their own care. Okay. All right, we do look forward to your questions and faxes. Again, the number to call is 1-800-953-2233. And if you would like to send us a fax, the area code is 410-786-1424. So, I don't think we have any calls. All right then, I guess we'll just move on, but please keep in mind that we will have another opportunity for your questions and comments. So we're going to move right on. We thank you for the ones that you did call in. We're going to continue now with the second half of our program. And in this half of our broadcast, we'll focus on assessing the problem through observation, interviews, record review with Dr. Greg Falls. And then finally, a panel presentation on possible F tags under which you may cite your findings. Well, now that we've caught up, let's hear from Dr. Falls. Now that we've reviewed the MDS items pertaining to oral health, let's see what a few coded items look like. Remember that the MDS oral and dental health items are only found on the full assessment form and not on the quarterly MDS. Section L item E reads, inflamed gums, gingiva, swollen or bleeding gums, oral abscesses, ulcers or rashes. Most of the residents that we've already seen have conditions that should check or code this item. Remember that as a dental director in nursing facilities, I find about 40% of my resident populations to have one of these conditions. Again, looking at Ms. Sylvia's slide, this MDS item should have been coded. She has inflamed, swollen and bleeding gums. Here is another resident who has an abscess. An abscess is usually the cause of swelling of this nature. Oral abscesses are infections caused when bacteria invades the teeth of the gums around the teeth because of decay or gum disease. This condition would certainly code this item. An ulcer can look like this. Many times, residents with ill-fitting dentures will have ulcers. A resident with an ulcer should have this item on the MDS coded. Ulcers can be found on the tongue, lips, cheek, palate and can be the beginnings of or can be cancer. Remember the white buildup on the tongue we saw earlier? That yeast infection can be considered a rash and would also code this MDS item. When a surveyor observes the presence of any condition described in the MDS item, like loose teeth, they should find the corresponding MDS item coded on the resident's MDS and a corresponding plan of care for the resident's oral or dental needs. And of course, the actions taken by the facility for this potential problem. The facility should also find in the chart additional documentation detailing the residents or the responsible party's desire or refusal of a dental referral and or treatment. The critical surveyor issues are the facility's correct assessment of the resident's oral health, the inclusion of the resident's oral health concerns in the care plan and the documented actions taken by the facility. Let's switch gears and look at the what, the how and the when of the survey process for oral dental issues. Specifically, what are important oral dental considerations of the survey process? How do we review specific components of the oral dental health and services and when do we review them? So what are the important oral dental considerations of the survey process? Keep oral and dental issues balanced in your survey. Please realize that our purpose today is not to make oral and dental issues take precedent over other survey issues. They should, however, be an integral part of the survey process and given no more, but certainly no less emphasis than other issues of care. Another important oral dental survey consideration is realizing that many different components of oral and dental health and services exist that may require investigation. These components include the condition of the resident's room and their oral hygiene aids, asking specific questions to the resident and to the staff, performing an oral inspection, a chart review that includes oral and dental issues and knowing the federal regulations concerning oral care and knowing how to correctly and reasonably apply those regulations when appropriate. It's also important that we realize it's virtually impossible to determine if a facility has correctly assessed a resident and provided the required dental services without looking in the resident's mouth ourselves. We'll get to an oral inspection of a resident's mouth in a few minutes. So moving on, how do we review specific components of oral and dental health and services? In general, our process to include oral health is identical to the survey process for all other resident issues. It begins with the initial tour of the facility and followed by the resident interview, observations and record review. More specifically, let's start the how with the initial tour of the facility. While touring resident rooms, look for the condition of and the presence of oral hygiene aids. Do the residents have toothbrushes or denture brushes? What are the brushes look like? Are they stored and cleaned properly? Do the residents have toothpaste or denture cleaners? Absence of brushes, toothpaste or denture cleaners in a resident's room can certainly tell us a lot about the oral hygiene that's being provided. Moving on to the resident interview, allow the resident and their environment to direct you in determining what questions you ask to the resident and or to the staff. I'd like to share with you a group of questions that I use to gather information about a resident's oral dental status. These questions were based on a list of probes, number 483.55 found in the guidance section of the federal regulations under tag number 411. You may ask a resident, does the staff help you clean your teeth? Does your mouth hurt? Is your mouth dry? Do you have any sores or ulcers in your mouth? Do you have natural or real teeth? If they say yes and they have natural teeth, you can then ask them, do your teeth hurt? Are any of your teeth broken? Do you have any cavities? Do your gums ever bleed? Can you chew well? Do you have any loose teeth? Some residents have full dentures or partials and we need to verbally address the presence of and the function of those dentures and partials with each resident as directed by our probes. You can ask, do you have a denture or partial? Do you need a denture or partial? If they have one, you can ask, does it fit well? Are they loose? Can you chew well with them? Do they hurt you? Again, answers to these questions may dictate further investigation through observation and a record review. Of course, cognitively impaired residents may not be able to answer appropriately, but attempt the exchange anyway. You may want to consider this. I've professionally been called to facilities on several occasions to treat a toothache for residents with no teeth. Confused residents may not answer appropriately as they sometimes revert back to past memories or they're afraid to divulge proper information. For this reason, I consider looking in the mouth essential to confirm what you've previously identified in your tour, your interview or to further investigate what you suspect from the presentation of the resident or their environment. This brings us to the observation segment of the survey and performing an oral inspection. To look in the resident's mouth, you must first inform the resident that you would like to do so and then ask their consent. The exchange could go like this depending upon the information you've gathered. I understand that you have a few cavities or I understand that your dentures don't fit and I'd like to look in your mouth. Is that okay with you? Cognitively impaired residents may need their oral and dental status assessed but may not be able to answer appropriately. As surveyors, you can observe the oral cavity and the end of these residents as a means of verifying MDS accuracy. The proper implementation of the care plan and the appropriateness of the care plan and services being provided to those residents also. Remember, you don't want to overlook another Miss Mary. The mouth is easy to assess if you think in terms of the four major components of oral health that you are reviewing. The teeth, the gums, the soft tissue and the appliances that a resident may have such as dentures or partials. To look it in the resident's mouth have a facility staff member, preferably a nurse or a CNA, help the resident open their mouth and retract the resident's lips. I can hear you now. What did he say? Get the staff to do what? Yes, I did say get the staff to help you as a dental consultant during surveys. I've never been refused help by nursing staffs to do this. Staff members have always done a good job and have been willing to help. Remember, someone in every facility should be familiar with looking in the mouth because looking in the mouth is required to properly assess the resident for the MDS and the care plan. Don't hesitate to ask for staff's assistance. I'd like to show you a video of how simple this process can be. I want you to notice on the video the man retracting the lips of this resident. He's the facility administrator and I purposefully chose the first cut of this video to further prove how well this can work by facility staff. As you'll see, he did a very good job. Notice how he's retracting the lips and we can see all the structures in the oral cavity that we need to review. Once the lips are retracted, you can look inside the resident's mouth and note your findings. A flashlight, which works best, or a pen light can greatly improve your ability to accurately assess the resident's oral condition. Most facilities have a light you can use. When viewing the oral cavity, make sure to review each of the four oral dental health components of the resident's mouth, teeth, gum, soft tissue, and dentures or partials. First, look at their upper and lower teeth or dentures or partials if they're missing teeth. After you've observed the teeth, dentures or partials in the mouth, have the resident, the nurse, or the CNA remove the dentures or partials and look at them to see if they're broken or dirty. Once they are removed, have the facility staff retract the lips again and continue. Now look at their teeth, gums, tongue, cheeks, and palate. This oral observation shouldn't take more than a few minutes and provides crucial information to you as you investigate if the resident's needs are being met. Make sure to record the time, date, and the names of all the people present when you perform your resident observation. Let's move on now to our record review. You now want to compare what you've found in the resident's mouth to the MDS in the resident's chart. Remember, it's a facility's responsibility to correctly assess the resident and produce an accurate MDS for oral and dental health. While reviewing the chart for all other survey issues, find the latest full MDS assessment, turn to sections K and L, and compare your findings from the resident, their mouth, and their room to the findings of the nursing facility staff on the resident's MDS. As you are reviewing the resident's care plan, determine if the care plan includes necessary dental services and or referrals. Obviously, absence of dental services or referrals in the care plan when oral and dental problems visibly exist is a care plan problem. If the staff misconditions on the MDS, it is likely that the care plan will be deficient regarding the resident's oral and dental needs. Next, as you review the nurses and the social notes in the chart, remember oral and dental health, where oral and dental referrals or services offered to the resident or to their responsible party. If they were, a clear documentation should be in the nursing and or social notes, detailing what was said and what was done. If the resident or their responsible party desires referrals, where they were provided. Again, these notes should also detail when the resident went to a dental office for an exam or for care. You also want to consider quality of life issues for each resident. Has the resident been afforded the services needed to maintain their highest level of function and comfort? Now that we know what the important oral dental considerations are and how to review specific components of oral and dental health and services, let's discuss when do we review them. For phase one residents, oral dental concerns should be considered for residents comprehensively assessed by the surveyor as appropriate. For those residents investigating each of the components of oral and dental health and services may be necessary. For phase two residents, oral and dental issues should be investigated when they are related to the chosen focus area. Let me give you an example. If in phase one you determine that the only dental concern for a resident was the lack of daily oral care, you could limit your investigation to the daily oral care procedures for that resident. Determining also, of course, if any harm had occurred. If, in contrast, you meet a resident having denture problems with a significant weight loss and a complicated medical history, you may investigate all of the components of oral and dental health and services for that resident. In other words, your survey investigation should follow the information gathered. Remember, however, it's virtually impossible to properly review the oral and dental status of a resident and determine if the proper services were provided without looking in the resident's mouth. So, when else do we include oral and dental issues in the survey process? Also, when considering specific residents, and as we now know, a health history of diabetes, strokes, heart attack, pneumonia, unexplained recurrent infection, or recent cognitive loss, can be adversely affected by poor oral health or lack of appropriate oral health services. For residents with a systemic disease, including oral and dental health in the survey process is certainly advised. Additionally, investigating oral, dental health and services is advised when a resident or a nursing facility staff reports oral problems to you on the initial tour of the facility. Also, when we observe the resident eating or speaking, and we suspect that oral problems may exist, further investigation is needed. For residents with significant weight loss, residents found to be eating less than 25% of their food, are residents with a history of malnutrition, dehydration, oral health and services are important and need to be investigated. As you see, most residents need at least some of their oral and dental health and service components investigated to ensure that the facility oral health assessment was accurate, that the proper services were provided to the resident. I want to now briefly discuss access to dental care for residents across the United States. There are many barriers to care that stop residents from receiving the dental treatment they need. Many state Medicaid programs don't provide dental services to adults. Many poor residents suffer from dental disease without hope of getting the treatment that they need. I believe, as I know you do, that no facility resident should live with pain, infection or a dental emergency. At this time in US history, the only answer for many of the facility residents is found in the existing long-term care regulations. Let's discuss now how the regulations can help our residents. One answer is found in the long-term regulations, tag number 411 and 412, specifically in the determination of routine dental service need versus an emergency dental service need for each resident. Routine dental services, as described in the guidance to surveyors, means an annual inspection of the oral cavity for signs of disease, diagnosis of dental disease, dental radiographs as needed, dental cleanings, fillings, newer repairs, minor dental plate adjustments and smoothing of broken teeth and limited prosthetic services. Taking impressions for dentures is also included as are the proper fitting of dentures. Emergency dental services in the guidelines include services to treat an acute episode of pain in the teeth, gums or palate, broken or otherwise damaged teeth, or any other problem of the oral cavity appropriately treated by a dentist that requires immediate attention. The guidance to surveyors goes on to specify that for Medicaid residents, the facility must provide the resident without charge all emergency dental services. We must all understand that many times significant oral diseases are present and the resident or the responsible party refuses dental treatment for a host of reasons. Also, the physician or treating dentist may themselves determine that the risk of treating a resident for their dental needs is greater than the benefits that the treatment will provide. So the treatment may be, so no treatment may be the best treatment. This is totally acceptable if documented properly in the chart. Because the resident has an obvious cavity does not mean that that cavity has to be filled. That obvious cavity however, should be assessed on the MDS, addressed in the care plan and a referral to a dentist must be offered to the resident or the responsible party. Additionally, a resident may not have dentures or partials to replace their missing teeth. If a resident is cognitively impaired or has a history of poor success with wearing a prosthetic, dentures or partials may not be appropriate. Again, the reasoning behind the services provided or withheld from a resident should be in the resident's chart. Remember, no treatment can be okay for residents. Let's discuss reasonable time frames. Some dental conditions require immediate treatment and or immediate assessment by a physician or a dentist as the resident may be in immediate jeopardy. I consider a broken jaw from a fall, teeth that have broken because of a fall, facial swelling from an oral dental source, severe pain in the teeth or gums or palate, grossly abscess teeth or severely loose teeth, gum disease with the presence of pus, large soft tissue ulcers or rashes, teeth that have been recently broken off due to decay that are causing pain or soft tissue lesions to fall in this category. I put together just for you a handout entitled Sample Oral Health Investigation Tools to help you include oral and dental health in your survey process. It contains the same sample instructions and questions I've suggested to you for your initial tour, the resident interview and the resident observation as well as the record review. It also contains the helpful hints I gave you to differentiate between a dental emergency and a routine dental need as well as my thoughts on reasonable time frames. You're in no way required to use these exact tools, but for your convenience, I wanted to give you a summary of the suggestions I've made on this broadcast. If you would like a copy of this summary, please contact me at my email, gfalse-dds-at-aol.com and you can also find that email address on the downloadable list of references that I mentioned to you before. Before I leave, I wanna introduce you to one more friend of mine. I first met Ms. Daisy Stewart in 1992 at a local nursing facility during a routine dental exam. She needed new dentures, but nicely stated that she thought she was too old and refused care. As God would have it, six months later, she lost those old dentures and I was able to make her at the new set of dentures she needed anyway. She did great with the new ones and wore them for the last eight years of her life. Ms. Daisy is a great example of how it can work. She had a need and because of a good dental program in her facility, we met her need and she lived those last eight years in good oral health. By the way, when I made those dentures for Ms. Daisy, she was 103 years old. She wore them in good health until she went to heaven at 111 years old. Oral health needs are definitely independent of chronological age. In closing, my personal and professional prayer is that you now have a heightened awareness of resident oral health and that you understand that oral health and dental disease can be a serious and potentially life-threatening component of resident overall health. I also hope that you've gained initial knowledge about the existing regulatory foundation that directs us to address these issues as surveyors, nursing facilities, and healthcare providers. With this information, you now possess the tools necessary to begin helping our nursing facility residents across this great country by incorporating oral and dental health into the survey process. Thank you. And thank you, Dr. Folson. Lord Willing, my choppers will hold out like Ms. Daisy's did. Well, as you can see, we've been joined by a new panel member, Virginia Martin, Surveyor, Louisiana Department of Health and Hospitals. Virginia, can you describe how to determine a facility's compliance with the regulations concerning dental care and oral hygiene? The basic means of determining compliance with these regulations begins with the assessment of the problem. According to the regulations, the facility must assess dental and nutritional status as discussed previously by other presenters in the conference. On survey, one way to determine compliance is to look for problems and then work back from there. Some of the flags that surveyors need to look for include residents who complain of dental problems, residents whose teeth are obviously in poor condition and who may have difficulty in chewing or even talking, their dentures may be falling out. One would need to go to the MDS and see if the dental condition has been accurately assessed. All right, who does the assessment in the facility? At this point, this could be a question of who is actually doing the oral assessment. Normally, we would expect a nurse to do the initial assessment of oral status. And if any question arises, a dental consult from a dentist should be able to resolve the question of whether or not there is a dental emergency. In fact, while the nurse may do the initial assessment, we find that other staff may be completing the MDS section relating to dental status. I have found dietary managers completing the MDS for this section, along with the nutritional status section and even doing the actual observation of the resident's mouth. As good as some of these auxiliary staff are, they're not usually trained to do dental assessments. All right, now what about the residents who need assistance with oral care? The need for assistance with oral care must also be assessed. In section CJ, the resident's ability to perform personal hygiene is assessed. The amount of assistance needed should be accurately assessed and the assistance must be given. If a resident is assessed as being able to take care of personal hygiene totally independently or with just setup help, and we observe that the resident in fact cannot or is not doing personal care independently, then the assessment is not accurate. It's also important when considering oral hygiene that the person caring for the resident on a daily basis be aware of the status of the resident's teeth and oral cavity. I have talked to direct care staff who say that they're doing oral care daily for a resident, but who don't know whether the resident has any teeth or not and are surely not aware of the condition of these teeth. What other problems do you find with direct care staff? Another problem with the caregivers is that they often don't know what to do if poor oral status is identified. On surveys, we have identified broken or rotten teeth in a resident's mouth and the aide will say, well, that has been like that for a couple of months, but never told anyone about it. Aid training should include not only proper methods for performing oral hygiene, but also what to look for relating to oral health and what to do and who to report to if a problem develops, such as a broken tooth or a resident complaining of pain or inability to chew. Okay, so what's the next step in determining compliance? After determining the status of the resident's teeth, the next step in determining compliance is to see if the wraps have been worked prior to determining the need to care plan. The wraps address each problem identified in the MDS and show how to work through a process to try to determine why the problem exists and what other factors in the resident may be contributing to the problem so that a workable plan of care can be developed. Okay, you just mentioned wraps and the need to care plan. Can you discuss this plan of care? Sure, the next step in determining compliance is to determine if the plan of care addresses all issues related to dental health, which are identified on the MDS or other assessment tool. If identified, the plan of care must address problems such as poor oral health, bad teeth, poorly fitting dentures, lost or broken dentures, mouth pain, the inability of a resident to care for his own teeth and refusal to allow staff to assist. Some residents may refuse care, but the care plan should reflect the facility's efforts to find alternative means to address the problem. Okay, Virginia, now we have a care plan. How do you determine if it's been implemented? Yes, after the plan of care has been developed, we do need to determine if it has been implemented and if the interventions planned are actually being followed. This means that if the care plan intervention for staff to clean the resident's teeth after each meal, then we should be able to observe the direct care staff cleaning the teeth. And it should be obvious by observation that the teeth are clean. If you can look at a resident while they're talking and see food particles and built up plaque on the teeth, then it is a clue that the teeth are not being cleaned daily. If there's no toothbrush in the resident's room and care staff can't find the toothbrush, it's evident that care is not being provided as planned. Okay, then how can you tell whether there may be a problem with the daily care? If the resident is admitted with his own teeth, which are not identified as being in poor condition and then a later assessment identifies carrier's teeth, there may be a problem related to providing care for the teeth. If proper daily cleaning and other oral hygiene was not actually being provided, this may have been directly related to the development of the carrier's teeth. If any of these steps, assessment, planning, implementation, have not been carried out, then the facility may be cited for non-compliance with the regulations regarding to oral care. Okay, thanks Virginia. Sue, let me address this question to you. Give me an example of a tag that may be cited and how a surveyor might document non-compliance. Tag F309 is an example of a tag that a surveyor may use to cite in its identified deficiency related to oral and dental conditions. This is a general care and services requirement. Usually dental services to maintain eating ability would be covered under F310, F311 or F312. However, for care and services not provided, that do not fit under the other tags F309 could be used. An example of deficient practice that may be cited at tag F309 would be untreated mouth pain. You would investigate to establish presence of mouth pain, its extent. Is it constant or related to specific activities as eating or chewing? Include interview of the resident if they are able. Can the resident describe the pain, its severity and duration? How has the pain affected the resident? How long has the resident indicated mouth pain or discomfort? Does the resident grimace when eating, refuse cold or chewy foods, interview staff including direct care and supervisory staff as to their awareness of the resident's mouth pain? How would staff describe the pain and its frequency, intensity and length of time that the resident had pain? Is there planned intervention? Remember, I indicated untreated pain. So the citation would need to indicate presence of mouth pain and the lack of adequate treatment of the resident's pain or discomfort. Record review should also be used to indicate facility awareness of the pain and what interventions were planned. As usual, document your observations and investigation. Okay, so describe the evidence that was gathered during the investigation that you would use to document the deficiency. The comprehensive assessment for a resident indicated the resident is having broken, loose and curious teeth. Interview with the resident revealed for the past four months, she has been having mouth pain when eating. Observation during the noon meal revealed grimacing while eating and leaving the majority of her food untouched. She said she was particularly bothered by hot or cold foods. The facility has not evaluated the pain or developed interventions to address the pain. Also, the facility has not referred the resident to a dentist. The citation I have described would most likely be given a severity rating of harm because the resident had pain that was not treated. You may also consider a cross reference to FTAG 411 or 412 as these requirements address the provision of dental services. Okay, before I come back to you, Virginia, because I have another question for you. Let me give you all the phone numbers. If you have questions, please take this opportunity to call in and ask. For phone questions, the number is 1-800-953-2233. That's 1-800-953-2233. If you'd like to fax in your questions, please call us at area code 410-786-411. 614-24, that's 410-786-1424. Virginia, let me come back to you. Discuss if you would F325 and maintaining nutritional status. The oral status of residents is closely related to maintaining their nutritional status and vice versa. One of the risk factors for malnutrition is poor oral health status. If the resident is unable to chew because of bad teeth, missing teeth, sores in the mouth or ill-fitting dentures, then it will be difficult for them to eat. It may take longer to eat because the food is difficult to chew. The food may get cold before the resident is able to complete the meal, thus causing the food to become unpalatable. Decreased intake of calories may lead to weight loss. If the food is mechanically altered because the resident is unable to chew the regular food, it may also be unpalatable and the resident may refuse to eat. Frequently, mechanically altered or pureed food is not as calorie dense as the regular diet, thereby decreasing the available calories. All right, how do you determine compliance with this regulation? In determining compliance with the regulation for maintaining nutritional status, we need to determine whether the resident with oral health problems has been assessed as being at risk for nutritional problems. The inability to chew can lead to decreased weight and malnutrition. When a resident stops eating, the facility should try to determine the reason rather than just deciding to give them a supplement. Determining whether the resident is having difficulty chewing is one of the first approaches that should be taken. Okay, is this what you see happening in facilities, Virginia? Unfortunately, what usually happens is that when the chewing problems are identified, the first response, rather than addressing the dental problem itself, is to alter the texture of the food and serve the resident chopped or pureed food which frequently lacks palatability. The food often lacks flavor and the appearance is not good, thus leading to a lack of interest in food and self-feeding which leads to decreased independence. The resident doesn't want to eat pureed food, refuses to feed himself and winds up being fed or even on a tube feeding. Quality of life is decreased and many residents lose the desire to live. Well then, Virginia, how can facilities prevent this decline? This is a far-reaching problem that can be headed off by assessing the dental condition and needs at the outset and providing appropriate care for the teeth and oral cavity. If the condition of the teeth and the mouth is maintained, the downward spiral of decreased intake and subsequent weight loss may be avoided. Well, how do you assess whether weight loss is avoidable? In assessing whether weight loss was avoidable, one thing we must determine is whether the oral status of the resident was considered and assessed. And if the risk for weight loss related to poor oral status was assessed and care planned, whether services to maintain oral health were provided, et cetera. All right, now what other regulatory area may involve oral and nutritional status? Another regulation to look at is TAG F-326. This regulation addresses the need to provide a therapeutic diet when there is a nutritional problem. The term therapeutic diet includes mechanically altered diets when needed. If the resident has trouble chewing because of poor oral health, we need to determine whether this was assessed and whether the physician ordered an alteration in consistency to assist in chewing. And if the diet was ordered, did the facility provide the appropriate consistency? All right, what do you look for in determining appropriate consistency? It's important that the consistency needed by the resident be evaluated accurately. As long as residents can tolerate soft or chopped foods, there's no need to give them pureed food. On the other hand, if pureed food is really the only thing they can tolerate, then we must be sure that the food given to them is pureed and at the correct consistency for them to be able to eat it. It's also important to see if there is any periodic reevaluation of the resident's ability to chew so that the consistency remains appropriate. In other words, if a resident is ordered a pureed diet while their dentures are being fitted or repaired, then when the dentures are returned, is the diet reevaluated and changed back to regular or soft as the chewing ability improves? All right, let's talk about F327 hydration. How is hydration related to oral and nutritional health? Hydration is very important in considering nutrition and oral status. If dehydration is suspected, it's important to check oral status also. Hydration is related to oral health in more than one way. If the resident is not eating due to poor oral health, then the total amount of fluid taken in may decrease since about a third of the total fluid we consume is found in the food we eat, and this may lead to dehydration. Okay, and what effects may dehydration have on the resident's status? As hydration status worsens and the resident's body fluid levels decrease, the mouth may become dry due to decreased saliva in the mouth. This may lead to an inability to flush bacteria from the mouth and teeth, leading to further decay of the teeth. Dry mouth and bad teeth may lead to further decreases in food intake, leading to decreased calories, fluid, protein, and then to worsening oral nutritional and hydration status. Dehydration may also cause increased confusion, which may lead to the inability of the resident to feed himself or to perform other ADLs, including caring for the teeth. This becomes a vicious cycle. One problem adding to the others as the resident becomes less able to care for himself and to take in adequate amounts of food and fluid to maintain his nutritional status. And before I ask you another question, Virginia, let me give you all the phone numbers again. Area code four faxes, area code 410-786-1424. And if you have a question that you would like answered by our panel, please call us at 1-800-953-2233. Virginia, how is hydration status determined? Hydration status is difficult to determine. Dehydration is defined in the MDS guidelines as a condition in which water or fluid loss, the output, far exceeds the fluid intake. In order to determine whether there is a problem with hydration, it would be necessary for the facility to keep intake and output records to see how much fluid the resident is actually taking in. If these records are being kept, the facility should be sure that they are accurate and accurate assessment of the total amount of fluid ingested. All right, now how can these records be used to determine compliance? Theoretically, these totals could be checked against say the physician's order for total fluids as in a tube feeding order or against the dietician's recommendations for the total amount of fluid needed by this particular resident. The difference between intake and output should be monitored to determine whether dehydration is present. Actually, what usually happens is that the record is incomplete or inaccurate and no one can actually tell how much fluid the resident is really getting. Accurate assessment of hydration status is then nearly impossible. All right, Virginia, a lot of great information. Thank you. Kathy, let me come to you. What other tags may be cited related to dental care and oral hygiene? The ADL tags, activities of daily living, may be used to cite inadequate oral hygiene. When you determine a resident lacks oral care or receives inadequate oral care, a deficiency may be cited at tags F310, F311, or F312. Let me briefly describe each tag. Tag F310 could be used when there is an... I'm sorry, when there is a avoidable decline in the resident's ability to provide oral hygiene. Avoidable declines may be, for example, a resident who has difficulty completing oral care because of arthritic pain. A decline in vision may make it difficult for the resident to judge how well they are cleaning their teeth. Confusion or memory loss may affect a resident's ability to provide adequate oral care. When the resident's abilities decline, determine if the decline was avoidable or unavoidable. Did the facility provide adequate services and or interventions to maintain the resident's abilities? For instance, a resident's ability to brush their teeth declines because of the resident's arthritic pain. What interventions has the facility planned to address the resident's pain and to assist the resident to be as independent as possible for oral care? Tag F311 is used when the facility fails to provide the resident with treatment or services to maintain or improve the resident's ability to provide oral care. The intent of this regulation is to stress that the facility is responsible for providing maintenance and restorative programs that will not only maintain but improve the resident's ability to maintain oral health. A potential for improvement would be based on the resident's comprehensive assessment. Tag F312 is used when a resident that is unable to care for themselves does not receive oral care or receives inadequate oral care. All right, Kathy, if you would describe evidence that a surveyor would want to include in a citation. For each of these three tags, the evidence gathered should include evidence from the resident's record. Review the resident's comprehensive assessment. Did the facility assess the resident's ADL performance and oral dental status accurately? Were there triggers for further assessment? Were the raps completed to further assess the identified problem related to the resident's oral care? Did the facility plan appropriate interventions? Did the facility address the risk factors and unique needs of the resident? Did the resident receive all the care and services necessary to maintain oral care ability? Your observation of the condition of the resident's natural teeth or dentures would be essential to support a citation at tags F310, 311, or 312. As you evaluate a resident's oral care, consider residents who are fed by non-oral means, residents with oxygen therapy or chronic illness such as diabetes. Each resident, even residents who are edentulous, should have evidence that the mouth and gums are being cleaned. Interview the resident when possible, or the resident's family and the facility staff about the oral care the resident routinely receives and the facility's oral health practices. How does the resident feel about the oral hygiene? Does it affect the resident's quality of life? For example, does the resident avoid others because of embarrassment about mouth odor or bleeding gums? Obtain and review the facility's policy for the provision of oral care. Include in the citation any pertinent information that supports the deficient practice. Depending on the findings, these tags could be cited at harm or the potential for harm. The severity of the deficiency would depend on the condition of the resident's mouth. All right, can you give us an example of a citation at F312? Yes, a deficiency cited at F312 may read something like this. The facility failed to ensure that oral hygiene was provided for two of the 14 dependent residents in a sample of 24 residents. The findings included. The facility failed to keep the resident's mouth in a clean and intact condition. Observations of resident number three reveal the resident had no upper teeth and the sixth lower teeth have heavy soft plaque and tartar buildup. The resident's gums were red and swollen. Due to the amount of buildup, the presence of decay could not be determined. This resident's MDS assessment indicated the resident required extensive assistance with ADLs. The resident's nursing care plan stated, fix toothbrush for resident and assist to brush teeth. On interview, two certified nurses' aides revealed that the staff did not brush the resident's teeth and that the resident was unable to brush their own teeth. The resident could not remember when their teeth were last brushed. This example includes a surveyors' observation of plaque buildup and red swollen gums and the staff's admission that they do not brush the resident's teeth. It also contains record review indicating the facility is aware the resident is dependent. Thank you, Kathy. Virginia, let me come back to you. What other area of the regulations can be used to cite the lack of dental services for nursing home residents? There is another area of the regulations where I have addressed nutrition concerns related to dental care. Tags F411 and F412 directly address provision of dental care for residents in nursing homes and skilled nursing facilities. F411 addresses skilled facilities and F412 nursing facilities, as Dr. Foltz has related earlier. Okay, well, when would you consider citing these regulations? When the nursing home residents are found having problems chewing and eating as a result of broken teeth or dentures and possibly losing weight as a result of not eating, the need for care and services to correct these problems is evident. F411 addresses the need for a skilled nursing facility to provide or obtain from an outside resource routine and emergency dental services to meet the needs of each resident. An additional amount may be charged these residents in this case and they need to promptly refer the resident with lost or damaged dentures to a dentist. F412 speaks to services provided by a nursing facility to meet the needs of each resident. Routine dental services must be provided to the extent covered by the individual state plan and referrals for lost or broken dentures must be made. Emergency dental services must also be provided and the guidelines at F412 state that these services must be provided without charge to the Medicaid resident, as Dr. Foltz addressed in his earlier presentation and he spoke about what constitutes routine and emergency dental services. The earlier question about when the facility would need to pay for services or what would happen to a resident whose family didn't have family or wasn't able to provide would fall under one of these two situations. Either the state plan would pick up the cost. If there is no part of the state plan that covers emergency services then the facility would be required to pay. The surveyor would need to review the record to see if documentation was available on what had been done to assist the resident with obtaining dental services and to inform the Medicare resident what the possible cost of the service would be. Okay, well how does this relate to other areas of the resident's status? Remember the importance of the resident's ability to chew a regular diet related not only to maintaining nutrition and hydration status but also maintaining mental and psychosocial status. It's vital that facilities understand the necessity of assessing resident's dental status and providing the needed care. In many cases if routine dental services are provided on a regular basis dental emergencies can be avoided. Even such a simple thing as daily oral care and cleaning of the teeth and having the teeth examined by a dentist regularly can go a long way to preventing the type of dental emergency which may cause the resident pain and result in increased ability to eat. Okay, but Virginia what about the residents who have broken and infected teeth? Just consider these medically compromised residents who have teeth which are broken and become infected for lack of services. The infection in the teeth may be a factor in other medical conditions such as diabetic control, heart disease including endocarditis and for residents with joint prosthesis and other conditions that were discussed earlier by Dr. Fulce. All right, Virginia in what situation would you consider writing a citation at these tags? Deficiencies have been written at Tag 412 on residents with obviously broken teeth and inflamed and infected gums for whom the facility failed to address or to assess the dental care needs of the resident or to make any attempt to provide needed services in these dental emergencies. All right, and one more question before we give our audience an opportunity to ask their questions. Remember folks, the numbers to call for questions and faxes 1-800-953-2233 that's for your questions. To fax in your questions, the number is area code 410-786-1424. Sue, F-250, social services. How is this tag related to dental care and oral hygiene? The facility must provide medically related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. The intent of the regulation is that sufficient and appropriate social services are provided to meet the resident's needs, including dental, oral, and denture care. You are aware it is the facility's obligation to meet the resident's social service needs and that it may not specifically be the social worker. However, there should be evidence that whoever is responsible is aware and makes attempts to arrange services for the resident's dental care needs. This may simply involve contacting the family regarding the dental needs if the family is involved in the care and follows through. On the other hand, it may be that the responsible staff notifies the family and the responsible staff needs to follow through to make the dental appointment and arrange for transportation if the resident must leave the facility for care. Additionally, the responsible staff may work with other agencies regarding arranging payment. All right, can you describe an example of what a deficiency might include in the documentation at F-250? The deficiency would include, for example, lack of knowledge of the resident's dental needs resulted in failure to make the necessary contacts or arrangements for the resident's dental needs, such as, observation of a resident in October of 2000 at 2 p.m. revealed that the resident had many missing teeth on both top and bottom. With one bottom tooth, which was loose enough that the resident could move it easily with her tongue. Record review of the social service designee notes dated in December of 1999, documented in Missing Bridge. No further documentation was found to indicate the status of the Missing Bridge. Interview on October of 2000 at 2 p.m. with two certified nurse aides assigned to the central hall confirmed that the bridge had been lost a while back. The current social service designee hired in February of 2000 was not aware of the Missing Bridge or of the condition of the resident's teeth. I would also like to say that during these presentations you have heard discussions regarding tags and regulations that could be used in determining non-compliance with dental and oral conditions. I think that it is agreed among the panel that there are additional tags that may be used to cite deficient practices related to oral health. You should choose the most appropriate tag for each citation by considering the regulation and the guidance to surveyors. All right, thanks a lot, Sue. And that concludes the panel presentation. So before we end this program, I would like to give you, our viewers, another opportunity to ask our panel questions and to ask questions of our panel. The number to call is 1-800-953-2233. If you'd like to fax in your questions, the number is area code 410-786-1424. And while we are waiting for you all to call in, Dr. Foles got a question for you. You know, we've heard that there's sometimes difficulty in finding dentists to provide care to nursing facility residents. Do you have any thoughts about that problem? Yes, on the short term, there are a few things that a facility could do and if they were in that condition. First would be to call the local dental society in the town or city where they are and try to find help that way. They may also want to contact the American Society for Geriatric Dentistry, which is located in Chicago, to possibly find some help. And if that, if all else fails, you can call me. I'll try to do the best I can to find someone in your area or your state to help you. But that's just one of the issues that's involved with nursing home residents and getting the care that they need. I think that there's a lot of other issues that stop residents from receiving appropriate dental care. To address those issues on a larger level, I would love to see us all form some type of national coalition to address these issues. More specifically, what can we do on a national level to affect things? If we could get our MDSs correct, it would provide us with good information on a national level. Right now, our MDSs show that only 3% of our patients have decayed or broken teeth or 0.8% of our patients or residents in the facilities have gum disease. If we could show the true percentages and the true prevalence of disease in our nursing facility population, we could use that information on a national level to fix some of the problems that we all know exist in getting residents' care. Okay, and before we come away from you, let's give your email address again, please. It's gfalzdds at aol.com. And false is spelled F-O-L-S-E. Yes. Okay, thank you. All right, we've got Denise calling us from Las Vegas. Denise, thank you for calling. Please go ahead with your question. Yes, I'd like to find out what you would do. Would it be a citation if you have a resident who had a non-emergency dental problem and the facility was waiting for approval of insurance or whoever to pay for it? So the condition continues and continues. I don't know if it's gonna continue. I'm just giving a hypothetical, but I just wanted to know is that a citation if there's...