Failure to Notify Residents of Grievance Resolutions
Penalty
Summary
The facility failed to follow its own grievance policy and procedures for three residents who had filed grievances regarding their care. Each of these residents had documented concerns, but the facility did not inform them verbally or in writing about the findings of the investigations or the actions taken to address their grievances, as required by the facility's policy. The grievance reports for these residents had sections left blank regarding notification of the concerned party, and there was no evidence that the residents received updates or copies of their grievance resolutions. Resident 2, who had diagnoses including difficulty walking, low back pain, and muscle weakness, required substantial assistance with daily activities. Resident 3, with muscle weakness, shortness of breath, and a history of falls, also required significant help with personal care. Resident 4, diagnosed with muscle weakness and morbid obesity, similarly needed substantial assistance. All three residents were able to understand and communicate, and each reported not being updated about the resolution of their grievances. Interviews with the residents confirmed that they were neither given copies of their grievance reports nor informed about the outcomes or corrective actions taken. Interviews with facility staff, including the Social Services Director and the DON, revealed that while the process involved filing the grievance and notifying the relevant department, there was no consistent follow-up with the residents regarding the resolution. Staff acknowledged that the records did not show any documentation of resident notification about the outcomes, and the facility's policy specifically required both verbal and written communication of investigation findings and corrective actions to the resident or their representative.