Failure to Timely Address Resident Grievance Regarding Mattress and Pain
Penalty
Summary
The facility failed to timely initiate and address a grievance for a resident who had ongoing complaints about discomfort caused by her mattress and back pain. The resident, who had a diagnosis of cellulitis in the right lower limb and a wound to the right heel, repeatedly informed staff that her mattress was uncomfortable and exacerbated her back pain. She reported her concerns to multiple staff members, including certified nurse aides and a nurse, and requested a different mattress and a recliner, which she had used at home. Despite these repeated complaints, no grievance was formally documented, and her requests were not addressed in a timely manner. The resident spent extended periods in her wheelchair due to the discomfort and was told on several occasions that a recliner could be provided, but this was not followed through until later. Interviews with facility staff revealed that the Director of Nursing was not aware of the resident's complaints or requests, and the staff assigned to check on the resident daily did not document or escalate the grievance. Additionally, registered nurses on the unit indicated that grievance forms were not readily available, and their process for handling concerns was to notify the relevant department or unit manager rather than completing a formal grievance form. The facility's policies required that grievances be documented immediately and investigated, but this process was not followed for the resident's ongoing complaints.