MDS item L0200 (Dental) often gets limited attention even though it fuels the Dental Care care area assessment (CAA), one of 20 CAAs that can be triggered in response to MDS coding (i.e., care area triggers or CATs) and then must be analyzed by the interdisciplinary team (IDT) to help develop individualized resident care plans. The following excerpt adapted from chapter 4, “Care Area Assessment Process and Care Planning,” of the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual explains the importance of the Dental Care CAA and shows the CAT logic:
Dental Care CAA
The ability to chew food is important for adequate oral nutrition. Having clean and attractive teeth or dentures can promote a resident’s positive self-image and personal appearance, thereby enhancing social interactions. Medical illnesses and medication-related adverse consequences may increase a resident’s risk for related complications such as impaired nutrition and communication deficits. The dental care CAA addresses a resident’s risk of oral disease, discomfort, and complications.
Dental Care CAT Logic Table
Triggering Conditions (any of the following):
1. Any dental problem indicated by:
L0200A (Broken or Loosely Fitting Full or Partial Denture) = 1 (checkmark) OR
L0200B (No Natural Teeth or Tooth Fragment(s) (Edentulous)) = 1 (checkmark) OR
L0200C (Abnormal Mouth Tissue (Ulcers, Masses, Oral Lesions)) = 1 (checkmark) OR
L0200D (Obvious or Likely Cavity or Broken Natural Teeth) = 1 (checkmark) OR
L0200E (Inflamed or Bleeding Gums or Loose Natural Teeth) = 1 (checkmark) OR
L0200F (Mouth or Facial Pain or Discomfort With Chewing) = 1 (checkmark)
When this CAA is triggered, nursing home staff should follow their facility’s chosen protocol or policy for performing the CAA. This CAA is triggered when a resident has indicators of an oral/dental issue and/or condition.
The information gleaned from the assessment should be used to identify the oral/dental issues and/or conditions and to identify any related possible causes and/or contributing risk factors. The next step is to develop an individualized care plan based directly on these conclusions. The focus of the care plan should be to address the underlying cause or causes of the resident’s issues and/or conditions.
L0200 also plays a role in the Review of Indicators that many providers choose to use to assess each CAA during care plan development. Note: The box at the end of this article excerpts Appendix C, “CAA Resources,” in the RAI User’s Manual to show how section L fits into the review for five CAAs: Dental Care, Communication, Nutritional Status, Feeding Tubes, and Pain.
Residents with poor dental status who previously have not had consistent oral care or who have portions of their dentition that are broken, cracked, or in poor quality have an increased number of bacteria in their oral cavity, says Renee Kinder, MS, CCC-SLP, RAC-CT, vice president of clinical services at Broad River Rehab in Asheville, NC. “As such, they are at higher risk for infection, particularly aspiration pneumonia (I2000), in addition to being at risk for reduced overall quality of life and health.”
Note: The Dental Care CAA also indicates that residents can have unstable diabetes (I2900) or endocarditis (I8000) related to oral infection, as well as poor nutrition (I5600) and mouth sores related to ill-fitting dentures (L0200C).
One often-overlooked source of information that nurse assessment coordinators (NACs) and the rest of the IDT can consult for oral/dental assessment and care planning information to prevent such problems is the speech-language pathologist, suggests Kinder. “The speech-language pathologist collects assessment data for K0100 (Swallowing Disorder) that integrates with L0200 assessment and care planning.”
Communication breakdowns between clinical and therapy teams in long-term care often boil down to semantics, says Kinder. “Often, the members of the IDT assess the same areas, but they use different language across the nursing team vs. physical therapy vs. occupational therapy vs. speech-language pathology vs. social work.”
NACs and speech-language pathologists should work together to understand how their roles coincide. To bridge the divide, NACs can better understand speech-language pathologists by learning more about their processes and the terminology they use. This will enable them to have a more productive discussion about the outcome of the speech evaluations, says Kinder. “In a bedside swallow evaluation for dysphagia, the speech-language pathologist evaluates the oral, pharyngeal, and upper digestive structures. Then, they assess how their findings impact the resident’s ability to swallow a variety of textures and viscosities,” she explains. “The bedside swallow evaluation includes some standard components.”
These components include the following:
The oral peripheral exam;
The oral mechanism exam;
An examination of strength and range of motion; and
The diet textural analysis.
“Before the speech-language pathologist looks at structure, function, range of motion, and coordination, they assess all of the oral cavity. Therefore, a very basic question that NACs can ask the speech-language pathologist is, ‘What were your findings in regard to dentition on the oral peripheral exam?’” suggests Kinder. “The IDT could get a wealth of information from what likely has already been completed on every dysphagia evaluation.”
In addition, most of the information from this portion of the speech-language pathologist’s evaluation also should be documented in the standard version of many long-term care electronic medical records, making it already accessible for NACs to review to find supporting documentation for coding section L, adds Kinder.
While nurses complete the MDS oral exams for annual and quarterly assessments, some residents may be more challenging to examine. “It can a bit intimidating, particularly if the resident has significant oral pain or discomfort during meals or poor dentition,” says Kinder. “However, nurses need to be able to do at least a preliminary assessment with the questions outlined in the RAI User’s Manual and then make timely referrals when necessary so that the appropriate professional can complete a full assessment and do further analysis of the problem.”
Note: The requirement for facilities to make appropriate, timely referrals and help residents obtain routine and 24-hour emergency dental care is addressed in F790 (Routine/Emergency Dental Services in SNFs) and F791 (Routine/Emergency Dental Services in NFs) in Appendix PP, “Guidance to Surveyors for Long-Term Care Facilities,” of the State Operations Manual. Also see the Dental Status and Services Critical Element Pathway (Form CMS-20070).
Care planning Q’s
The provision of oral care is a regulatory requirement under F676 (Activities of Daily Living (ADLs)/Maintain Abilities) and F677 (ADL Care Provided for Dependent Residents). Note: For details, see Appendix PP of the State Operations Manual. Also see the ADL Critical Element Pathway (Form CMS-20066).
“IDTs know that oral care needs to be completed. However, even teams that do a stellar job collecting assessment data may fall short with care planning,” says Kinder. “There should be a formal care plan in place that details what oral care looks like for each individual resident on a daily basis. That plan could vary based on the findings in L0200, as well as K0100 (Swallowing Disorder). It needs to be truly purposeful for each resident.”
For example, if K0100B (Holding Food in Mouth/Cheeks or Residual Food in Mouth After Meals) is coded, the team needs to consider whether morning and evening oral care is sufficient, says Kinder. “Does a CNA need to be assigned to use oral swabs to thoroughly clean the oral cavity after meals so the resident doesn’t return to their room with portions of their meal still in there? Knowing this type of information when planning for care can make a huge difference in reducing the risk for aspiration pneumonia and other issues.”
First meeting with the speech-language pathologist to discuss their findings on the oral peripheral exam will help NACs generate more conversations that can then inform care planning, says Kinder. “Follow-up care-planning questions could include, for example, ‘Based on your findings on the oral peripheral exam, how can we assess an appropriate daily oral health and hygiene plan?’ and ‘What can the resident do for themselves?’ Speech-language pathologists can offer insights about potential problems and potential strengths to inform care planning.”
Including the resident in the conversation is also important, notes Kinder. “Nursing home staff are doers. While that is generally a positive, it also can on occasion create excessive disability when residents are admitted to the nursing home. This goes across all of the different activities of daily living, including oral care.”
Kinder offers this example: When a resident is admitted to a facility, the CNAs set up their room the same way they do for all residents, putting their underwear and socks in the top dresser drawer, their shirts in the closet, and their toiletries, including their toothbrush and toothpaste, in the bedside table. However, this resident has lived in the same home environment for 45 years, and they folded their t-shirts in the top drawer, separated their underwear in the second drawer and their socks in third drawer, and put their toothbrush and toothpaste by the bathroom sink.
“It’s not that this resident has an inability to complete the activities of daily living,” explains Kinder. “The issue is that the facility’s staff members have totally restructured their environment. Transitions from different environments cause increased stress, which can present as reduced cognitive ability. However, often the IDT can help orient the resident by asking the right questions: ‘What is your normal routine? How did you structure your environment? How did you complete your oral care previously?’”
Armed with this knowledge, NACs can work with the resident, speech-language pathologist, and other IDT members to determine how to honor the resident’s preferences and maintain their function, says Kinder. “The IDT may even be able to help the resident return to their prior level of function. If, for example, the resident has had a stroke or an exacerbation of a disease process and now has right upper-extremity weakness that requires assistance with oral hygiene, knowing their previous routine helps the IDT structure that activity in a way that is meaningful to them and that can help them return to that prior level of function.”
Need help customizing care plans and training staff?
Oral care staff education and training resources include the following:
CMS provides the Head to Toe Infection Prevention Toolkit (ZIP), which addresses best practices in oral care and has resources for customizing oral care, including for residents with diabetes, residents with cognitive impairments, residents who recently had surgery or are short-stay, and residents who are receiving blood thinners.
Mouth Care Without a Battle offers continuing education credits for nurses and CNAs. While online CE requires a nominal fee, other resources are free, including a Mouth Care Basics Worksheet, Mouth Care Strategies for Resistive Behaviors, and other tools.
The Canadian suite, Brushing Up on Mouth Care, has multiple resources for long-term care and other continuing care providers, including assessment and care planning tools, care cards, and The Brushing Up Video Series:
o Brushing Techniques & Oral Health Products;
o Considerations for Palliative Care;
o Considerations for Dementia;
o Oral Health Assessment Tool (OHAT); and
o Oral Health Basics.
The University of Kentucky College of Dentistry’s Nursing Home Oral Health page has video and PowerPoint trainings, task lists for residents based on dental status, CNA competencies, pre-tests/post-tests, and other resources.
MDS Section L’s Role in the Review of Indicators for Five CAAs
Diseases and conditions that may be related to poor oral hygiene, oral infection:
Sores in mouth related to poor-fitting dentures (L0200C)
Diseases and conditions that may be related to communication problems:
Poor-fitting dentures (L0200)
Dental/oral problems (from Section L and physical assessment):
See Dental Care CAA
Broken or fractured teeth (L0200D)
Bleeding gums (L0200E)
Loose dentures, dentures causing sores (L0200A)
Lip or mouth lesions (for example, cold sores, fever blisters, oral abscess) (L0200C)
Mouth pain (L0200F)
Reason for tube feeding:
Unable to swallow or to eat food and unlikely to eat within a few days due to physical problems in chewing or swallowing (for example, stroke or Parkinson’s disease) (L0200F, K0100D)
Factors that may impede removal of feeding tube:
Chewing problems unresolvable (L0200F)
Mouth pain (L0200F)
Diseases and conditions that may cause pain (diagnosis OR signs/symptoms present):
Dental problems (section L) (L0200)
Source: Appendix C, “CAA Resources,” RAI User's Manual.
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