Failure to Document and Investigate Resident Grievances
Penalty
Summary
The facility failed to properly document, investigate, and resolve grievances raised by a resident's representative regarding the care of a resident with diagnoses including diabetes, a sacral pressure ulcer, colon cancer, and dementia. The resident was cognitively intact and required maximum assistance with activities of daily living and transfers. On two separate occasions, the resident's representative voiced concerns and made accusations about the resident's care, including the presence of a bug and bite marks found during a wound clinic visit. Although these concerns were discussed in meetings and documented in social service notes, there was no documentation of the specific concerns, investigation, or resolution, and a grievance form was not initiated as required by facility policy. During interviews, the Social Services Director acknowledged that no grievance forms had been completed for the concerns raised, despite regular meetings and documentation in progress notes. The facility's policy required staff to record grievances on a designated form and for the Grievance Official to document actions taken toward resolution. The lack of formal grievance documentation and investigation constituted a failure to honor the resident's right to voice grievances without discrimination or reprisal, as well as a failure to follow the facility's established grievance policy.