Failure to Maintain and Track Resident Grievance Documentation
Penalty
Summary
The facility failed to maintain a written record of a grievance and did not follow its own grievance policy for one resident. The resident's daughter filed a grievance after observing her mother in pain, with her legs pressed against the edge of a table, resulting in wounds on her shins. The daughter completed the facility's grievance form and submitted it to the receptionist, who placed it in the DON's mailbox. However, the grievance form was not included in the facility's records when requested by the surveyor, and staff were unable to locate it. Interviews with staff revealed that the receptionist confirmed receiving the grievance form and placing it in the appropriate mailbox, but was unaware of what happened to it afterward. The Social Services Director stated that grievances are typically relayed to the appropriate department and that the Administrator should be aware of all grievances. However, the Social Services Director did not receive the form and only became aware of the concern after speaking with the resident's daughter days later. The Director of Nursing and Administrator also could not account for the missing grievance form. The facility's policy requires that the Administrator oversee the grievance process, track grievances through to their conclusion, and issue written decisions to the resident. The policy also states that staff receiving a grievance must record the specifics on the designated form and that all actions taken to resolve the grievance should be documented. In this case, the facility did not maintain the required documentation or follow the established grievance process, resulting in a failure to honor the resident's right to voice grievances without discrimination or reprisal.