Failure to Document and Resolve Resident Grievance Regarding Missing Personal Item
Penalty
Summary
A resident with multiple complex medical conditions, including muscle wasting, neoplasm-related pain, diabetes, morbid obesity, immunodeficiency, chronic respiratory failure, cancer, and acute kidney failure, reported a missing gray scrub top to laundry staff. The resident, who was cognitively intact, expressed frustration about the missing item and stated she had reported it to a laundry aide approximately two months prior. The laundry aide confirmed receiving the complaint but did not document the grievance, report it to a supervisor, or escalate it to the Grievance Official as required by facility policy. The aide also indicated there was no log for lost or missing items and was unsure of the process for unresolved missing items. Further interviews revealed that the Housekeeping/Laundry Manager only became aware of the missing item after being informed by the laundry aide a week prior to the survey. The manager described an informal process of searching for the item and, if not found, eventually notifying medical records to replace it, but did not mention any documentation or formal grievance filing. The Nursing Home Administrator stated that staff are expected to report missing items to the Social Worker, search for the item, complete a grievance form, and replace the item if not found. However, in this case, the facility failed to document, investigate, or resolve the grievance in accordance with its own grievance policy.