Failure to Document and Resolve Resident Grievances
Penalty
Summary
The facility failed to maintain a system for documenting grievances and demonstrating prompt actions to resolve them, as required by its own grievance policy. The policy stated that residents or their representatives must be informed of the findings of any grievance investigation and corrective actions within ten working days. However, for one resident, the facility did not document the steps taken to address or resolve grievances submitted by the resident's representative, nor did it show evidence of communication with the representative regarding the outcomes. The resident's representative reported filing several grievances, including concerns about staff communication and the resident's head support in her wheelchair. She stated that she was not informed of any resolutions and was unaware of who was responsible for handling grievances at the facility. Observations confirmed that the resident was poorly positioned in her wheelchair, and staff interviews revealed that the head support was not included in the care plan or Kardex, and staff had not been trained on proper positioning after the grievance was filed. A review of the grievance forms showed that while the concerns were documented, the sections for actions taken and follow-up were left blank. There was no documentation of outreach to the resident's representative or resolution of the grievances. Although updated forms were later provided with signatures and notes indicating resolution, these were signed by the resident rather than the representative who submitted the grievances, and there was no evidence that the representative was notified or approved the resolutions.