Failure to Document and Investigate Resident Grievance for Missing Dentures
Penalty
Summary
The facility failed to document and investigate a resident's grievance regarding lost dentures, as required by its grievance policy. A resident, who was moderately cognitively impaired and wore full dentures, was discharged home, after which the resident's representative discovered the dentures were missing. The representative contacted the facility and spoke with the Social Services Director (SSD), who stated she would look for the dentures and follow up. The SSD later informed the representative that the dentures could not be found, but did not document the incident as a grievance or initiate a formal investigation as required by facility policy. Review of the facility's grievance logs for the relevant month showed no documentation of the missing dentures. Interviews with staff revealed inconsistent knowledge and practices regarding the grievance process, with some staff unsure of the proper forms or procedures to follow when a grievance is reported. The SSD admitted she did not complete the grievance form or conduct an investigation because she believed the resident had thrown the dentures away. The SSD attempted to arrange a dental appointment for replacement dentures but did not follow up further with the resident's representative. The facility's policies require that grievances be documented, investigated, and resolved promptly, with the Administrator or a designated Grievance Coordinator responsible for oversight. In this case, the lack of documentation, investigation, and communication regarding the missing dentures constituted a failure to honor the resident's right to voice grievances and to resolve them without discrimination or reprisal, as required by regulation and facility policy.