Failure to Document, Resolve, and Respond to Resident Grievances
Penalty
Summary
The facility failed to ensure that its grievance policy included all required elements and did not properly document, resolve, or provide responses to residents or their responsible parties for grievances. The policy lacked provisions for anonymous grievance filing, identification of a grievance official, the right to a written decision, immediate action to prevent further violations during investigations, mandatory reporting of certain violations, detailed written grievance decisions, appropriate corrective actions, and maintenance of grievance records for at least three years. These omissions were confirmed through review of the facility's grievance policy and interviews with facility leadership. Multiple concern forms reviewed for thirteen residents revealed that for eleven residents, key sections such as immediate actions, summary of findings, and corrective actions were left blank or incomplete. Questions regarding whether the concern was confirmed, if a written decision was requested, and whether the resident or responsible party was notified of the resolution were frequently unanswered. Signature lines for department heads and the NHA were often unsigned, indicating a lack of accountability and follow-through in the grievance process. Specific grievances included missing personal items such as clothing and money, concerns about room cleanliness, staff behavior, missed showers, and rough handling by staff. In several cases, documentation failed to show that the concerns were investigated or resolved, and there was no evidence that residents or their representatives were informed of outcomes. Interviews with facility leadership confirmed these deficiencies in both policy and practice.