Failure to Address and Document Grievances Regarding Dialysis Chair Discomfort
Penalty
Summary
The facility failed to initiate and act on grievances regarding the discomfort of dialysis chairs, as reported by two residents receiving in-house dialysis. Both residents, who were cognitively intact and had significant risk factors for skin impairment, voiced repeated concerns about the hardness and discomfort of the dialysis chairs during their treatment sessions. One resident, with a history of pressure ulcers and ongoing wound care, specifically reported that the chair exacerbated her pain and discomfort, and that she had communicated her concerns to both the dialysis center and facility staff. The other resident also reported significant discomfort and pain from sitting in the dialysis chair for extended periods during her treatments. Despite these complaints, there was no evidence that the facility formally documented or addressed these grievances in accordance with its own grievance policy. The policy required prompt efforts to resolve grievances, written responses, and investigation by a designated grievance officer. Interviews with facility staff, including the wound care nurse, Rehab Director, ADON, and social worker, revealed a lack of clarity and follow-through regarding the residents' complaints. Staff acknowledged that a grievance should have been initiated but could not provide documentation or a clear account of how the concerns were addressed. Additionally, review of the facility's grievance log showed no entries related to the dialysis chair complaints from either resident. The issue was only discussed informally during an interdisciplinary team meeting after repeated resident complaints, and no formal trial or intervention was documented prior to surveyor inquiry. The lack of documented action and failure to follow the established grievance process resulted in the residents' concerns not being properly addressed or resolved.