Failure to Promptly Address and Document Resident Grievances Regarding Missing Personal Items
Penalty
Summary
The facility failed to ensure prompt efforts were made to resolve grievances for two residents regarding missing personal clothing items. One male resident with intact cognition and a history of dementia and chronic obstructive pulmonary disease reported that all his underwear had been destroyed in a facility laundry fire. He stated he had informed several CNAs, nurses, and laundry staff about the loss, but no one provided information or resolution regarding his missing underwear. Interviews with laundry staff and the Housekeeping/Laundry Supervisor confirmed awareness of the loss, but no formal grievance was filed, and the items were not replaced. A female resident with intact cognition and diagnoses including personality disorder, bipolar disorder, major depression, and anxiety reported missing a pair of pants valued at $40. She stated she had informed the Administrator, but no action was taken, and her pants were neither found nor replaced. The Housekeeping/Laundry Supervisor acknowledged being aware of the missing pants and that extensive searches had been conducted without success, but again, no grievance was filed. Interviews with facility staff, including the Administrator and Social Worker, revealed a lack of communication and understanding regarding the grievance process. Staff members were either unaware of the need to file a grievance or did not convey the information to the appropriate personnel. Review of the facility's grievance log confirmed that no grievances were recorded for either resident during the relevant period, despite the facility's policy requiring all grievances to be documented and resolved within three working days.