Failure to Follow Grievance Policy for Missing Denture
Penalty
Summary
The facility failed to ensure that a resident's right to voice grievances was honored and that the facility's grievance policy was followed when a resident's denture went missing. The resident, who had dementia and moderate cognitive impairment, was under hospice care and had an activated health care proxy (HCP). The HCP discovered the missing denture during a visit and was informed by staff that it had been missing for several days. The HCP was given a grievance form to complete, which she returned the following week, but did not receive a response from the facility. Review of facility records showed that no grievance form was completed by staff at the time the missing denture was first reported, and there was no documentation in the medical record regarding the missing denture or any efforts to resolve the issue. The facility's policy required staff to complete a grievance form for verbal complaints and to forward it to the Grievance Official for timely review and resolution, but this process was not followed in this case. Interviews with staff revealed uncertainty about whether a grievance form had been completed and a lack of clarity regarding who was notified in administration. The administrator confirmed that he was not aware of the missing denture until he received the completed grievance form from the HCP several days after the initial report. The failure to document and follow up on the grievance in accordance with facility policy resulted in a lack of prompt response and resolution for the resident and their representative.