Failure to Process Grievance and Arrange Timely Dental Services for Missing Dentures
Penalty
Summary
The deficiency involves the facility’s failure to timely address a resident grievance regarding missing dentures and to ensure provision of dental services as outlined in facility policy. The resident, an adult with diagnoses including lipoprotein deficiency, plasma-protein metabolism disorder, glaucoma, legal blindness, right ear hearing loss, essential hypertension, low BMI, and right foot pain, was cognitively intact with a Brief Interview for Mental Status score of 14. An inventory list dated prior to hospitalization documented upper and lower dentures, while a subsequent inventory list after readmission showed no dentures. Upon readmission, the resident reported the dentures missing, but no grievance form was completed by the staff who received the concern, despite facility policy requiring grievances/concerns to be filed and followed up within 72 hours. The resident reported repeatedly asking to speak with the Administrator, being told the Administrator was on vacation, being redirected to the Assistant Administrator without follow-up, and speaking with Social Services without receiving any response regarding the missing dentures. The facility also failed to ensure timely referral and provision of dental services after the dentures were reported missing. Facility policy required that if dentures are lost or damaged, the resident must be promptly referred for dental services within three days, or the facility must document what was done to ensure the resident could still eat and drink and any extenuating circumstances for delay. Staff interviews confirmed that the Social Services staff reported the missing dentures to administration but did not complete a grievance form, and the Assistant Administrator acknowledged awareness of the concern without initiating the grievance process. The DON stated that residents who report missing dentures are to be referred to dental services, but was unsure why this resident was not seen by dental services before discharge. Although the Activity Director indicated the resident was placed on a monthly sign-up list for dental services, the resident was not actually seen by the dental provider prior to discharge, and the resident reported not seeing any dental services or being informed of any follow-up on the dentures during the stay or after discharge.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.