Failure to Address and Resolve Resident Grievances Regarding Missing Laundry Items
Penalty
Summary
The facility failed to honor residents' rights to voice grievances without discrimination or reprisal and did not establish or follow an effective grievance policy regarding missing laundry items. Multiple residents reported missing clothing and personal items to staff, but the facility did not consistently document these grievances, conduct thorough investigations, or provide resolutions. Resident council meeting minutes and interviews revealed that several residents experienced ongoing issues with missing clothing, with some items never being found or replaced, and residents often ceased pursuing the matter after initial reports to staff. Surveyor observations and interviews with staff, including the Laundry Director and Nursing Home Administrator, revealed a lack of a clear and consistently implemented process for labeling residents' clothing. Many clothing items remained unlabeled, as evidenced by approximately 80 pieces of clothing on an unlabeled cart in the laundry area. Staff acknowledged that the process for labeling and tracking clothing was not well defined or enforced, and that staff training on this process could not be substantiated with documentation. The facility's grievance logs showed some instances where missing items were found and returned, but other cases were not documented or resolved, and there was no evidence of prompt or systematic efforts to address the broader issue. Interviews with residents and staff further highlighted the facility's inadequate response to grievances about missing laundry. Residents described having to keep personal records to track their belongings, and staff often relied on informal methods or other departments to search for missing items. The Director of Nursing acknowledged the ongoing problem with missing laundry due to improper labeling and confirmed that the facility had not resolved this concern. The lack of a clear, documented process and failure to address residents' grievances led to unresolved losses of personal property for several residents.