Inadequate Investigation of Resident Grievance on Call Light Response
Summary
The facility failed to ensure that a resident's grievances regarding call light response times were thoroughly investigated, violating the resident's rights. The resident, who was cognitively intact, reported an incident where they were left in a wet bed for over 45 minutes after requesting assistance. The resident expressed dissatisfaction with the response from staff, including a CNA who was reportedly dismissive and left the room without completing the task. The resident's grievance was documented, but the investigation was inadequate as it did not include interviews with other cognitively intact residents or all staff involved. The grievance investigation was conducted by the Social Activity Director, who admitted to not interviewing any other cognitively intact residents or the other staff members involved in the incident. The Director of Nursing also confirmed that no additional staff or residents were interviewed, acknowledging that a thorough investigation should have included these steps. The grievance log indicated that a call light audit was performed and staff were counseled, but the investigation lacked comprehensive input from all parties involved. The Administrator was unaware of the extent of the investigation and did not ensure that a thorough investigation was conducted. The facility's grievance policy requires that all grievances be investigated with accounts from all individuals involved, but this was not followed. The failure to conduct a thorough investigation into the resident's grievance about call light response times highlights a deficiency in the facility's handling of resident complaints and adherence to resident rights.
Penalty
Resources
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Surveyors found that the facility did not provide residents with required and accessible information on how to file grievances and how to contact the grievance official. On multiple nursing units and in the dining area, grievance boxes with forms were present but lacked posted details about the grievance official’s name and contact information, residents’ right to file grievances orally, in writing, or anonymously, and the expected time frame for grievance review. On one nursing unit, no grievance box was located at all. Although grievance information was posted on a hallway bulletin board, it was placed too high for a person seated in a wheelchair to easily see, limiting accessibility. The NHA confirmed the failure to provide this information on all nursing units.
A resident with depression, anxiety, moderate cognitive impairment, and urinary incontinence, care-planned for q2h checks and assistance with toileting, was found by a visitor to be soaking wet, unusually agitated, and reporting they had been told to wait to be changed and referred to with a derogatory remark. The visitor filed a written grievance alleging abuse/neglect related to delayed incontinence care and removal of the resident’s tablet as a consequence. Although an incident report noted that the matter was reported to the state and that the resident was not soaking wet, a CNA who actually changed the resident later reported the resident’s brief, pants, wheelchair, and socks were soaked and that the resident was acting timid and repeatedly saying they had to sit for five minutes, but this CNA was never interviewed. The DON acknowledged not investigating the resident’s behavior or interviewing this CNA, and the grievance official acknowledged the facility did not fully investigate or communicate findings and resolution to the complainant, resulting in a failure to follow the facility’s grievance policy.
A resident filed multiple written grievances against a nursing staff member, including one that lacked any attached investigation report, and reported never receiving a response from administration. The facility’s policy required the administrator to investigate and respond to written grievances within ten days, but staff interviews showed confusion about where grievances should be placed, with some believing they should go to the administrator and others thinking they belonged in the DON’s office. The ADON acknowledged that grievances were left in various locations, did not consistently reach administrative staff, and that staff had not been in-serviced on grievance procedures. An LPN reported assisting the resident with a grievance and sliding copies under the administrator’s and ADON’s office doors, yet leadership later stated they were unaware of that grievance due to a systemic failure in grievance review.
The facility did not ensure residents understood how to file grievances and failed to document and track grievances and their resolutions. Residents reported that they only voiced concerns during resident council and were unclear about the grievance process otherwise, and the designated Grievance Officer could not produce a grievance log or forms. The DON acknowledged the grievance process was informal and lacked clear documentation. In addition, a resident with significant cardiac and neurologic conditions and moderately impaired cognition had a representative who raised multiple concerns about care coordination, communication, discharge planning, call bell response, personal property, preferences, and nutrition, but these grievances were largely handled verbally, with no consistent documentation of how each concern was addressed or resolved.
A resident reported to an RN that clothes and money were missing and complained that nothing was being done, but the concern was not communicated to the social services staff member responsible for investigating missing items and filing grievances. The social services staff member stated she was unaware of the report and therefore did not initiate her usual process of searching for the items, filing a grievance form, or arranging replacement. Review of the grievance log over several months showed no entry for this resident’s missing items, despite a facility policy requiring that grievances be recorded, promptly addressed, and resolved within a specified timeframe.
A cognitively intact resident reported ongoing concerns about inadequate night shift incontinence care and lack of regular checks. A grievance was filed on the resident's behalf by the SW, but the grievance form only noted that staff education would occur and did not document how the concern was investigated, what findings or conclusions were reached, whether the grievance was confirmed, or when a written decision was provided. The SW stated she routinely assigned grievances to departments and verbally confirmed follow-up but did not record investigation details, outcomes, or dates, and did not inform the complainant verbally or in writing of the resolution, reporting she did not know this was required. The Administrator stated grievances were expected to include full documentation of investigation, findings, resolution, and notification to the complainant and was unaware this was not being done.
Failure to Provide Accessible Grievance Information and Grievance Official Contact Details
Penalty
Summary
The deficiency involves the facility’s failure to provide required information to residents about how to file grievances and how to contact the designated grievance official. On the North nursing unit, surveyors observed a grievance box with forms available, but there was no information posted or provided regarding the grievance official’s name and contact information, residents’ right to file grievances orally, in writing, or anonymously, or the expected time frame for completion of the grievance review. The same issue was identified on the South nursing unit, where a grievance box with forms was present but lacked the required informational details. On the West nursing unit, surveyors were unable to locate a grievance box at all, indicating that residents on that unit did not have the same visible access to grievance forms as on other units. In the dining area, a grievance box with forms was present, but again, there was no accompanying information about the grievance official’s identity and contact information, the right to file grievances orally, in writing, or anonymously, or the expected time frame for review completion. These observations showed that residents did not have complete and accessible information about the grievance process in multiple common areas and units. Surveyors also observed a bulletin board in a hallway leading to the dialysis area, activities room, and conference room where information about the grievance official and filing grievances was posted. However, this information was placed far above the eyesight of a person seated in a wheelchair, limiting accessibility for residents who use wheelchairs. During an interview, the Nursing Home Administrator confirmed that the facility failed to provide information regarding how to file a grievance and information on the grievance official on all three nursing units, corroborating the surveyors’ findings.
Plan Of Correction
The information on the grievance box has been corrected to include the Grievance official's name and contact information, the right to file grievances orally, in writing, or anonymously and the expected time frame for completion of the grievance review. This information has been posted at eyesight level of a person seated in a wheelchair. A Grievance box has been added to the West Unit. The Administrator has educated the Social Worker who is the Grievance officer on the required posting with the required information. A new grievance form/process will be put into place to monitor the time frame for completing the grievance in the expected time frame. The Administrator/Designee will Audit for the placement and required information for the Grievance regulation and 10% of resident grievances for the timely completing weekly times four and monthly times four. Results of these audits will be presented to the QAPI committee for review and recommendations.
Failure to Thoroughly Investigate and Resolve Resident Grievance Regarding Incontinence Care and Staff Conduct
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate and resolve a grievance alleging neglect and disrespect toward a resident, as required by its grievance policy. The resident had depression, anxiety, moderate cognitive impairment, occasional urinary incontinence, and required moderate assistance with toileting, with a care plan directing staff to check the resident every two hours, ask about toileting needs, and ensure they were clean and dry. A collateral contact reported arriving to visit the resident and finding them soaking wet and agitated, with behavior that was not typical for the resident. The collateral contact documented in a written grievance that the resident’s tablet was off, the resident appeared upset, and the resident reported being told they had to wait five minutes to be changed and that staff would change their “nasty *ss” in five minutes, leading the collateral contact to believe the resident had been given a consequence of no tablet and sitting in wet clothes, which they characterized as abuse/neglect and requested immediate removal of the responsible staff and a report filed. The facility documented receipt of the grievance and created an incident report indicating the matter was reported to the state agency, and that the unit manager interviewed the collateral contact and the resident, with the resident described as confused and denying being soaking wet. The incident report stated that a different nursing assistant was assigned to assist with the brief change and that the unit manager believed the resident was not soaking wet, and that the resident and collateral contact were satisfied when they left the room. However, a CNA who actually changed the resident reported that the resident’s brief was soaked through their pants onto the wheelchair and their socks were soaked, and that the resident was timid, repeatedly saying they had to sit for five minutes, and not acting like themselves; this CNA stated they were never interviewed or asked about the grievance or the resident’s condition. The DON acknowledged not interviewing this CNA or investigating the resident’s behavior and why they were upset, and the unit manager did not recall whether the collateral contact was present during follow-up and did not believe they followed up with the collateral contact regarding the grievance. The administrator, identified as the Grievance Official, stated the facility should have thoroughly investigated the grievance and discussed findings and resolution with the collateral contact, indicating the grievance process was not fully carried out in accordance with policy and WAC 388-97-0460.
Failure to Receive, Track, and Investigate Resident Grievances per Policy
Penalty
Summary
The facility failed to ensure grievances were received, tracked, and investigated by an identified grievance official in accordance with its grievance policy. Review of the grievance binder showed multiple grievances filed by Resident #23, including one dated 01/07/26 that had no investigation reports attached. The facility’s undated grievance policy stated that the administrator should inform the complainant of the findings of the investigation within ten days of receiving the written grievance report and outline actions to correct identified problems. Resident #23 reported having filed multiple grievances against a nursing staff member and stated they had not received any response from administrative staff regarding these grievances. Staff interviews revealed confusion and inconsistency regarding the handling and routing of grievance forms. CNA #1 stated that nursing staff were required to take written grievances directly to the administrator, while CNA #2 believed grievances were being placed in the DON’s office but was unsure. The ADON stated that grievances were being placed by staff in various locations throughout the facility and were not reaching administrative staff promptly, and acknowledged that staff had not received in-service training on grievances. The ADON, DON, and administrator reported they were unaware of the 01/07/26 grievance due to a systemic grievance review failure. LPN #1 stated they assisted Resident #23 with the 01/07/26 grievance, made two copies, and slid them under the office doors of the administrator and ADON, yet the grievance was still not received or acted upon by the designated administrative staff.
Failure to Inform Residents of Grievance Process and Document Grievances and Resolutions
Penalty
Summary
The facility failed to ensure residents were informed about the grievance process and that grievances were documented and tracked in accordance with its grievance policy. The Social Services/Admissions Coordinator, identified as the Grievance Officer, reported that while they interviewed residents and emailed Administration about complaints they could not resolve, they were unable to provide a grievance log or grievance forms. During resident council, multiple residents stated they voiced concerns in the meeting but did not know how to file grievances outside of that setting, and there was no documented evidence listing grievances or the facility’s responses. The DON stated that grievances should be monitored by Social Services with documentation of the nature of the complaint and the resolution, but acknowledged that the process was informal, dependent on circumstances, and not completely clear, with no forms or documentation used to track grievance progress and resolution. For one resident reviewed for care planning, the facility did not consistently address and document multiple grievances raised by the resident’s representative. This resident had diagnoses including cerebral infarction, occlusion and stenosis of the left carotid artery, and myocardial infarction, with the admission MDS indicating moderately impaired cognition and involvement of the resident and family in assessment and goal setting. The representative reported numerous concerns regarding miscommunication between nursing and rehabilitation, discharge planning, appointment scheduling, call bell response time, personal property, resident preferences, nutrition, and proper diet, all of which were communicated to Administration via email and paper copies. Although a family meeting was held to discuss these concerns, the Social Services/Admissions Coordinator and the DON confirmed there was no documented evidence of how each grievance was addressed or resolved, and that most concerns were handled verbally without formal documentation or investigation of every complaint.
Failure to Log and Address Resident Grievance About Missing Personal Items
Penalty
Summary
The facility failed to honor a resident’s right to voice grievances and to ensure that a grievance regarding missing personal items was reported, logged, and resolved according to policy. Nursing documentation dated 3/20/25 by an RN (V12) recorded that resident R5 stated he had clothes and money missing and that no one was doing anything about it. During a later interview, the RN stated she documented the note on 3/30/25 and indicated that her usual practice when a resident reports missing items is to report them to the social services staff member (V9), but she could not recall whether she actually reported R5’s missing items to V9. In a separate interview, V9 stated that when a resident reports missing money or clothes, she spends 48 hours attempting to locate the items and, if unsuccessful, files a grievance form and replaces the items, but she was not aware of R5’s report of missing items. Review of the facility’s Grievance Complaint Log from January 2025 through October 2025 showed no grievance filed for R5’s missing clothing or money, despite the resident’s report. The facility’s undated Grievance/Complaint Policy states that residents have the right to voice grievances without discrimination or reprisal, that prompt efforts will be made to resolve grievances, that the disposition of grievances will be recorded on the grievance and complaint log, and that grievances will have a disposition within seven working days of being filed. This deficiency centers on the facility’s failure to ensure that R5’s grievance about missing clothes and money was communicated to the appropriate staff, entered into the grievance log, and processed in accordance with the written grievance policy.
Failure to Complete and Communicate Required Written Grievance Decision
Penalty
Summary
The facility failed to honor a resident's right to voice grievances without reprisal by not completing and providing a written grievance decision with all required components. Resident #67, who was cognitively intact, had a grievance form completed on 3/5/26 by the Social Worker (SW) regarding concerns about night shift staff not being attentive, not providing incontinence care during the night, and not checking on her every two hours. The grievance form only documented that education would be provided by the Staff Development Coordinator and did not include how the grievance was investigated, a summary of pertinent findings or conclusions, a statement as to whether the grievance was confirmed or not confirmed, or the date a written grievance decision was provided to the resident. During an interview, Resident #67 reported she continued to experience issues with incontinence care not being provided routinely on night shift and stated she had raised these concerns during a care plan meeting. She indicated she did not know whether her concern had been addressed and had not been verbally informed of any grievance decision or received a written grievance decision. The SW reported she was responsible for managing grievances and described a process in which she completed the grievance form, assigned it to the appropriate department, and verbally followed up with that department, but she did not document the investigation, findings, resolution, or dates on the grievance form. She also stated she did not follow up with the individual who filed the grievance to inform them of the investigation, findings, or resolution and did not provide written notification of the grievance outcome, indicating she was unaware these steps were required. The Administrator stated that grievances should include documentation of investigation, findings, corrective actions, resolution, and notification to the complainant, and was not aware that the SW was not completing these steps.
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