Failure to Follow Up and Maintain Resident Grievances
Penalty
Summary
The facility failed to follow up on grievances for two residents who were cognitively intact. One resident reported filing grievances regarding missing personal items, including an arm sling, backpack, purse, and a box of crackers, but did not receive any follow-up from the facility. The Social Services Consultant and Social Services Director were unable to locate the grievances, and the Director did not know where the original forms were kept. Another resident reported an incident where another resident, who was known to wander, entered his room and sat on his bed. The resident was upset due to the other resident's incontinence and requested his sheets be changed. He informed a CNA and the Weekend Supervisor, who completed a grievance form and placed it in a designated location for the DON to review. However, the DON did not recall seeing the grievance, and the Executive Director and Social Services Consultant could not locate the form. The facility's policy required all grievance forms to be signed off by the Executive Director/Grievance Official and maintained on-site for at least three years, but this procedure was not followed.