Failure to Promptly Investigate and Resolve Resident Grievance
Penalty
Summary
The facility failed to follow its Grievance Policy by not promptly investigating and resolving a complaint made by a resident regarding an incident during a transfer. The resident, who had significant medical conditions including cerebral infarction, hemiplegia, and dysphagia, was dependent on staff for most activities of daily living. The incident involved the resident's head being bumped during a transfer for a shower, which was reported by the resident's spouse to an LPN. Both the LPN and the DON examined the resident and found no injury, but no further investigation or documentation was completed at that time. The facility's grievance log later documented the complaint, but the investigation and assessment were not initiated until a month after the incident. The Grievance Officer confirmed that the facility did not follow its policy, which requires prompt investigation, communication with the resident, and thorough documentation. There was no evidence of interviews with the resident, staff, or witnesses, nor was there a root cause analysis conducted immediately following the complaint. The lack of timely follow-up and investigation resulted in the facility not meeting its own grievance resolution standards.