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� " MICHIGAN DEPARTMENT OF CORRECTIONS 

PRISONER/PAROLEE GRIEVANCE FORM -

L, · I I J4835-4247 10/94 

CSJ-247A 

l Date Received at Step I

� 

I I Grievance Identifier: I I 

, 

What attempt did you make to resolve this issue prior to writing this grievance? On what date? ---,--=--=-----=-----::-c:-:-:-:-:--:­

If none, explain why. 

State problem clearly. Use separate grievance form for each issue. Additional pages, using plain paper, may be used. 

Four copies of each page and supporting documents must be submitted with this form. The grievance must be submitted 

to the Grievance Coordinator in accordance with the time limits of OP 03.02.130. 

. r 

RESPONSE (Grievant Interviewed? 0 Yes 

.11 

;l

Respondent's Signature Date 

Respondent's Name (Print) Working Title 

• 

Date Returned to I \ { Gricvant: "' \ I

If resolved at Step I, Grievant sign here. 

Resolution must be described above. 

1 

Gricvant·s Signature

If No, give explanation. If resolved, explain resolution.) 

t 

( l J

Reviewer's Name (Print) Working Title 

Grievant's Signature 

DISTRIBUTION: White, Green, Canary, Pink� Process to Step One; Goldenrod- Grievant

Exhibit 5 - Dearduff's Grievance

Case 2:14-cv-11691-LJM-MKM ECF No. 249-6, PageID.7267 Filed 06/06/18 Page 1 of 5
' ' 

li-�'t I

Step I Grievance Response 

Grievance Number: 

Prisoner Name: 

Prisoner Number: 

Prisoner X was 

STF 2016 06 060112Al 

Dearduff 

732738 

was NOT interviewed. GIVE REASON: 

SUMMARY OF COMPLAINT: 

The Grievant states that he has been unable to· get his teeth cleaned, two fillings completed and a partial completed by Dental. 

INVESTIGATION INFORMATION 

Per the Dental Department, the Grievant needs to send a request to Dental for cleaning and he wiH be put on the list. 

He does not qualify for a partial because he is missing too many teeth for a partial to hold. 

He sent a Dental Request on 4/13/16 for tooth pain and he was evaluated.on 4/13/16; no treatment�eeded for Dental, 

The Grievant sent another request to Dental on 5/12 complaining of pain. The Grievant was evaluated by Dental on 5/12/16 and 

there were no abnormalities noted and Dental states that if the ain continues they will extract tooth #12. 

SUMMARY 

. The Grievant is encouraged to send a Dental Request for cleaning and ifhe experiences any oral pain. 

RESPONDENT NAME: TITLE: 

RESPONDENT SIGNATURE: DATE: 

REVIEWER NAME: TITLE: 

REVIEWER SIGNATURE: DATE: 

Exhibit 5 - Dearduff's Grievance

Case 2:14-cv-11691-LJM-MKM ECF No. 249-6, PageID.7268 Filed 06/06/18 Page 2 of 5
- I .,J" '., 

' MICHIGAN DEPARTMENT OF CORRECTIONS

PRISONER/PAROIRl�EVANCE APPEAL FORM

ADMINISTRATIVE ASST 

4835-4248 5/09 

CSJ-247B 

Date Received by Grievance Coordinator

at _Step II: JUL 13 2016 &7F 

Grievance Identifier: I I I I I I I I I I I I I I

-/{, -Ou, -OUJDI _!/-tJ:?A-/ 

INSTRUCTIONS: �1111� TO BE USED TO APPEAL A STEP I GRIEVANCE.

Th� white copy �e�ievance Form CSJ-247A (or t 

with a Step I response in a timely manner) MUST be attached to the 

II and Step III. 

e not been provided

'IIYlll.llll:Al::1'111 appeal it at both Step

AUG 10 2016 

I the::: I grievance response to Step II, y ur appeal should be directe to:

r=._,,c-lE.fc5'-"'=-,.�....-�<.#-Jo-==- by .c..--f!;i--Jcp. If it is not submi �i�f:11!.-thl,tttcffls= nsidered terminated.

If you shou.ld decide to appeal the response you receive at Step II, you should send your Step III Appeal to the Director's

Office, P.O. Box 30003, Lansing, Michigan, 48909. 

Name (Print first, last) 

Joey Dnrduff 

Number 

--- -------

Institution 

1732731· STY 

Lock Number Date of Incident Today's Date 

•-1S3 ,.,_, fl..;.201 6 7..-11-19'14 

STEP II -_ 

Reason 

_

for

:A)Jpeal Al� the_ stsp 81e ,-.Owe by J� ·� "1it:h 111B � by M-Aa �

'P/ � an· thlt �-•,fJf; S1F � staff, their behavior - - · .. __ -_- 6, -� 1D 1aU a 81:Qq

r � W!9C of 44-X�

r �. en 1.-..7•6� �

_l 

ait6. 

h&S pt'Oll1d!d &Jith a m::h reeded 

It S'DJld be d.il.y roted 1-aiever, 

fi!Ung'i.n 

fhat td'lile ny 1m1h 

·m, a,· "'I 'larth, 

·1&'9 

fllith 

betng·fll.laf,

authar � �

<f -·-.btfatwed 

Jt:h :th& Orlntist, · l!llt · · ..iii, M, 1tet I was gl:d.na- ta bl! plaa!ld an tte· list far a partial af'tar.-.-all. Id.._ ""8t 's· tlul 

,cplain in grmt drrteil "1at care 

:rt l'IIIIB1rB to ti! an. I an !!BSl.l1'e \OJ ta&ever, that wtever· csre I'm d!niad, will ts neticulnaJy tD:llllll'dm. It wU

I· an �' mi, -1ha tB'd.al of care is causirg pl!d.n, 51 tr, diffioJl.ty l!llting, -S"lf 

:bi.nitriratiw 

U1 a.rtlin! tu., 

Prc:aiss, 

1hie anict v1.olatBs 1he Jar. It will elm rae rff/ End all pl!Dple .f.rwalvecf� As ·bS cr:,,t1ru! �

_]:� l:l!g1n 1D reSl!all:h O:rlzm's mle in 1his treatment miial as ..U. Sime �fur Jrtn Pm:11

Lstrict 21, hass· � his chsire to 5111! sane· ct.,a,ge wlthin 1he Mutdgm O!f.sI bent of Om:ectians, as evidarcad 

!!f1ata Bill t-.b. 932., ·jjllllffiap6 I will anta:t him m W!ll, 1n a, effort fbr tr:a l:lflBl."!O=Y. 

STEP II - Response Date Received by 

Step II Respondent:

18 2016 

----�--- -------

Respondent's Name (Print) 

Date Returned to

Grieva� l l l l

STEP III - Reason for Appeal St=p Tt...o Respordent, Patricia Lam, F?-J, 89-J, states in he

r resp:inse, "1-b.iever, baeE

c:n the eligibility criteria ccrrtaired in the current MXC Deital Protocol, IT W1lil AFflEAR TI-lAT GRID/ANT HAS TOO r,w

POSTERIOR TEETI-l Sffil � TO [UllIFV FOR A PARTIAL ID.1'Tl.K. " Ulder tJ,ose aithori ty, have yru f.EOPle created 

protocol, 1,.hich allOJJS you m deviate frcrn A) 03.03.13:J paragrcp, :,G, ,. tliich requires you ta �ide health c� ih,

is consistent with contanporary stmdards of nedlcal pra::tice in ihe ccrrm..n,i. ty?1

' P.:re you suggestirg -that people in ii

comutl. ty are being deni� partials based Lp.Jn row mchy teeth are present? PD 01 • ()i. .11 D paragr8ji, 11C, n states 11Ea

e:iJ:icy dira:tive a-cf DCM �ives authority fmn sta1l.rtB, erlninistrative rule, or crurt ardar PID MJST BE a:JJSISTEI

lrlffl I APf1.:EA[I£ s=FA"R::FFE5 .0.\EI AE»m�o.ni � � l.[ n �EASE F!Dlctoe: M'I PARTIAi , SO MI I r.AN EAT lr[THl [ Ar,N PAIN· 

�O IE: Only a copy of this appeal and the response will be returned to you. 

STEP III - Director's Response is attached as a separate sheet. 

DISTRIBUTION: White - Process to Step III; Green, Canary, Pink - Process to Step II; Goldenrod - Grievant

Exhibit 5 - Dearduff's Grievance

Case 2:14-cv-11691-LJM-MKM ECF No. 249-6, PageID.7269 Filed 06/06/18 Page 3 of 5
Michigan Department of Corrections STF-1606-601-llAl 

Grievance Step II Response DEARDUFF 732738 

Grievant claims that he has been subjected to an unreasonable delay re: provision of 

dental care, specifically a teeth cleaning, two fillings and a partial denture. Grievant 

states he was seen by Dental staff in December, 2015 and was told he could expect the 

aforementioned treatment "in the coming months ... and it is now 6/16/16, with no 

treatment in sight." 

Review of the electronic dental record reveals that grievant was evaluated on 12/3/15 and 

subsequently listed for cleaning, fillings and prosthetics. Initial tooth debridement was 

completed on 12/10/15. However, due to the sensitivity of grievant's teeth and his oral 

hygiene status, it was determined that further cleaning would require local anesthetic. 

This was partially completed on 7/19/16 when half of grievant's mouth was scaled and 

debrided following the administration of local anesthetic. The remainder of grievant's 

mouth will be similarly cleaned next week. Multiple fillings have been completed this 

month and grievant remains listed for more. At the conclusion of this process, the issue 

of the partial will be considered. However, based on the eligibility criteria contained in 

the current MDOC Dental Protocol, it would appear that grievant has too many posterior 

teeth still present to qualify for a partial denture. Loss of anterior (front) teeth is not 

among the current criteria for such prosthetics. 

Grievant is assured that every effort is made to see dental patients as swiftly as possible. 

It appears that some of the treatment planned for grievant has been completed. Should 

grievant experience adverse and/or worsening symptoms while waiting for the final 

dental appointments on his current treatment plan, he is encouraged to promptly contact 

the Dental Clinic at his facility. 

No further resolution can be offered at this time. 

Patricia Lamb. RN, BSN 

Respondent Name 

(J'atricia Lam6. fR!N: fBS!JI 

Respondent Signature 

JI, 

July 27, 2016 

Date 

Exhibit 5 - Dearduff's Grievance

Case 2:14-cv-11691-LJM-MKM ECF No. 249-6, PageID.7270 Filed 06/06/18 Page 4 of 5
Sten ill Grievance Resoonse 

JOEY DEARDUFF 

STF 16060601 

732738 

Grievant alleges he has been denied timely access to de(}tal services. 

.. . 

All relevant information within the electronic medical record has been reviewed. Step I and 

Step II appropriately addressed this grievance and are affirmed at the Step ill appeal. In 

accordance with PD 04.06.150 (0) Prisoners requiring urgent dental services shall be seen 

as quickly as possible ... Prisoners on the waiting lists for routine dental services shall be 

seen in the order of placement on the lists. Treatment priority shall be based on the clinical 

and professional judgment of the dentist. No violation has been identified. 

Grievance appeal denied. 

Response of Bureau of Health Care Services 

Approved:�#� 

R.fuha.rdD.Russ 

R Har augh, RN 

Grievance Section Office of Legal Affairs

Ref.# 25214 

C: Warden 

Regional Health Care Administrator 

Grievant 

Northern 

Date: 9/7/2016 

Date: o/t;/Jb 

SEP 14 2016 

Date Mailed 

Exhibit 5 - Dearduff's Grievance

Case 2:14cv11691LJMMKM ECF No. 2496, PageID.7271 Filed 06/06/18 Page 5 of 5