Failure to Promptly Address and Resolve Grievance Regarding Missing Dentures
Penalty
Summary
The facility failed to ensure that a grievance regarding a resident's missing bottom dentures was promptly addressed and resolved to the satisfaction of the complainant. The grievance was filed by the resident's family member, and the facility's Grievance/Concern Log indicated the concern was resolved within two days. However, documentation revealed that the facility did not designate a specific individual or department to handle the grievance, and there was no documented conclusion or summary of findings. The log also did not indicate whether the grievance was resolved to the satisfaction of the resident or their representative. Interviews with facility staff, including the Nursing Home Administrator (NHA), Risk Management Consultant (RMC), Business Office Manager (BOM), and Social Service Director (SSD), revealed inconsistencies and gaps in communication and documentation. The BOM reported only one documented contact with the family on the day the resident left the facility, and a follow-up attempt was made nearly two months later. The SSD was unaware of the grievance and confirmed there were no social service notes in the resident's record regarding the missing dentures or related conversations with the family. The facility's policy required prompt efforts to resolve grievances, assignment of concerns to appropriate departments, and documentation of resident or representative satisfaction, none of which were fully met in this case. The resident involved had multiple medical diagnoses, including a femur fracture, diabetes, alcohol abuse, and malnutrition, and was transferred to the emergency room and did not return to the facility. The admission inventory indicated the resident had both top and bottom dentures, but the form was undated. Progress notes did not document the representative's concern or any facility communication regarding the missing dentures. The lack of thorough investigation, documentation, and follow-up led to the failure to resolve the grievance in accordance with facility policy.