Failure to Investigate and Document Resident Grievances
Penalty
Summary
The facility failed to file and investigate grievances reported by a resident's representative for one resident who had significant care needs due to ALS and other medical conditions. The resident, who had limited mobility and communication abilities, sent multiple emails to the ADON reporting that staff were not responding to her call light, were rough and rude during care, and were not providing timely assistance with toileting and breathing treatments. These grievances were sent on three separate occasions, but there was no documentation that they were logged or investigated according to facility policy. Interviews with facility staff revealed that the ADON received the resident's emails and forwarded them to the administrator, but did not retain access to the emails after a company change. The DON and social worker both stated that grievances should be documented and addressed promptly, but neither recalled receiving or documenting the specific complaints from this resident. The administrator acknowledged receiving some complaints but did not have documentation of addressing the emails sent to the ADON, and stated that if she was not aware of a grievance, she could not address it. A review of the facility's grievance log showed only one complaint from the resident during the relevant period, despite multiple emails and verbal reports of concerns. The facility's grievance policy requires staff to guide residents in filing grievances and to document and address all complaints, but this process was not followed for the resident's reported issues. As a result, the resident's grievances were not formally investigated or resolved as required by policy.