Failure to Follow Grievance Policy and Protect Resident Rights
Penalty
Summary
The facility failed to follow its Grievance and Complaint Policy and Procedure in multiple instances involving several residents. In one case, a resident with end stage renal disease and other significant health issues complained to an LVN that a CNA refused to warm up the resident's meal after returning from hemodialysis, resulting in the resident eating a cold breakfast. The LVN did not report the complaint or initiate the grievance process as required by facility policy, and the assigned Social Services Assistant was unaware of the complaint. This led to a delay in addressing the resident's concern and the resident being assigned the same CNA again, potentially causing distress. Another incident involved a resident with diabetes, ESRD, and chronic kidney disease who repeatedly complained about the food being too salty despite being on a renal diabetic diet. The dietary staff did not follow standardized recipes for the resident's therapeutic diet, and the grievance process was not properly followed. The Grievance Official did not follow up with the resident regarding the findings of the investigation, and there was no documentation of communication with the resident about the results of a test tray or any resolution of the complaint. A third deficiency occurred when a resident with congestive heart failure and other conditions reported missing home medications at discharge. The LVN did not notify the Social Services Assistant of the complaint, and the medications were not documented in the resident's belongings inventory. The Social Services Assistant stated that if notified, a search and grievance log entry would have been initiated. The lack of documentation and follow-up resulted in the resident's grievance about missing medications going unresolved, causing distress to the resident.