Failure to Assist Resident in Filing and Resolving Grievance
Penalty
Summary
A resident with multiple chronic conditions, including chronic atrial fibrillation, heart failure, morbid obesity, and bowel and bladder incontinence, reported that she pressed her call light for assistance during a bowel movement and waited over two hours for staff to respond. When a CNA eventually arrived, the staff member refused to clean her because she was still having a bowel movement, leaving her in an unclean state until a nurse later provided care. The resident communicated her dissatisfaction and intent to file a grievance to the Social Services Assistant (SSA) during morning rounds, but did not receive any updates or follow-up regarding her complaint. A review of the facility's grievance log showed no record of a grievance filed by or on behalf of the resident for the incident in question. Interviews with facility staff, including the Social Services Director (SSD) and the Administrator, confirmed that the grievance process was not initiated as required by facility policy. The staff member who received the complaint did not complete a grievance form or ensure the concern was formally documented and investigated, resulting in a lack of prompt action and communication with the resident about the status of her grievance. Facility policy mandates that all grievances be documented, investigated within a specified timeframe, and that residents be kept informed of progress and outcomes. In this case, the failure to file and investigate the grievance promptly, as well as the lack of communication with the resident, constituted a violation of the resident's right to voice grievances without discrimination or reprisal and to receive timely resolution and updates regarding her concerns.