Failure to Investigate and Document Resident Grievance
Penalty
Summary
The facility failed to ensure that grievances were thoroughly investigated, properly documented, and that appropriate corrective actions were taken for a resident who reported being rushed and handled roughly during personal care by a CNA. The resident, who had hemiplegia and hemiparesis following a stroke, was alert, oriented, and able to communicate her needs, despite expressive aphasia. After the incident, the resident's daughter reported concerns to nursing staff, and although the nurse checked on the resident and found no visible injuries, there was no further follow-up documentation in the medical record from the time of the complaint through the resident's discharge. Interviews with facility staff revealed a lack of clarity and consistency in the grievance process. The Social Services Director was unaware of how grievances were being tracked or resolved and reported no grievances for the relevant months. The Administrator stated that grievance forms were available, but during the survey, no forms were found in common areas or at the Social Services Director's office. The DON acknowledged that there was no documentation to show that the grievance had been addressed or that actions were taken to prevent further violations. The facility's policy required grievances to be tracked, investigated, and followed up within a specified timeframe, but these procedures were not followed in this case.