Failure to Document and Resolve Resident Grievances Regarding Missing Personal Items
Penalty
Summary
The facility failed to follow its grievance procedure and make prompt efforts to resolve grievances regarding missing personal items for three residents. One resident with intact cognition reported missing multiple clothing items and stated she had informed staff but received no follow-up or resolution. Review of the facility's grievance log revealed no documentation of her concerns, despite a registered nurse recalling that a missing item slip had been completed previously. Another resident with moderately impaired cognition was overheard by a nurse complaining about a missing sweater, and a third resident with intact cognition reported missing several clothing items to multiple staff members. In both cases, there was no record of these grievances in the facility's grievance log. Interviews with staff confirmed awareness of the missing items, but there was inconsistency in documenting and following up on these grievances. The facility's policy requires that all grievances be logged, investigated, and resolved promptly, with communication maintained with the resident throughout the process. However, no grievance forms or documentation were found for the missing items reported by the three residents, indicating a failure to adhere to the established grievance policy and procedures.