Failure to Promptly Address and Document Resident Grievances Regarding Missing Clothing
Penalty
Summary
The facility failed to ensure prompt efforts were made to resolve grievances for two residents who reported missing clothing items. One resident, an elderly female with chronic obstructive pulmonary disease, diabetes, and heart failure, reported missing a pair of black pants and a green sleeveless V-neck shirt. She stated that the items had been missing for several months and that she had informed a staff member, though she could not recall who. Despite her reports, the missing items were neither found nor replaced, and no grievance was filed regarding her complaint. Another resident, also an elderly female with congestive heart failure, atrial fibrillation, and muscle weakness, reported missing a pair of black pants for several months. She consistently brought up the issue during resident council and town hall meetings, and it was documented in meeting notes. Despite her repeated complaints, the missing pants were not replaced until much later, and no formal grievance was filed. Interviews with staff confirmed that the missing clothing was reported to laundry and supervisors, but there was no documentation of a grievance or timely resolution. Record reviews and staff interviews revealed that the facility's grievance policy was not followed, as grievances regarding missing clothing were not documented or investigated as required. The social services designee and other staff acknowledged that complaints about missing clothing were brought to their attention, but grievances were not always filed unless the resident expressed significant distress. The facility's policy required prompt investigation and written response to grievances, which was not observed in these cases.