Failure to Promptly Resolve Resident Grievances Regarding Missing Personal Items
Penalty
Summary
The facility failed to promptly resolve grievances for a resident who reported multiple missing personal items, including valuable jewelry, clothing, and sentimental belongings. The resident, who was cognitively intact and had a history of cancer, neurogenic bladder, anxiety disorder, depression, and unspecified mood disorder, reported the loss of these items over a period of months. Despite submitting at least three written complaints and concern forms, the facility did not locate or replace the missing items in a timely manner. Documentation showed that the resident was instructed to select replacement items, but there was no evidence that the process was completed or that the resident was notified of a resolution or expressed satisfaction with the outcome. Review of facility records revealed that the required Personal Effect Inventory was not completed at the time of the resident's admission, but only after multiple complaints had been filed. The facility's policy required that missing items be investigated and resolved within two weeks, but this was not adhered to in the resident's case. Interviews with staff and the Nursing Home Administrator confirmed that the process for investigating and resolving grievances was not consistently followed, and key documentation regarding resolution and resident satisfaction was missing.