Failure to Resolve and Communicate Outcomes of Resident Grievances
Penalty
Summary
The facility failed to follow up and resolve grievances for multiple residents regarding missing personal items, including money, clothing, and other belongings. Documentation for grievances submitted by residents was incomplete, with forms lacking information on whether concerns were resolved, if results were communicated to residents, and whether residents were satisfied with the outcomes. In several cases, there was no evidence that investigations were completed or that residents were informed of the findings, despite facility policy requiring such actions. Residents reported missing items such as cash, clothing, and personal care items, and in one case, a resident with visual impairment reported unauthorized charges on his debit card after staff assisted him with purchases. Interviews with staff revealed that some were not involved in investigations or were unaware of the outcomes, and that the previous administrator was responsible for handling certain incidents but did not complete the required documentation. Resident Council minutes and group interviews further confirmed that concerns about missing items and unresolved grievances were ongoing and not addressed in a timely or effective manner. The facility's Quality Assistance Policy required that grievances be investigated, findings reported to the administrator, and results communicated to the resident or their representative. However, review of records and interviews indicated that these steps were not consistently followed. The lack of a specific policy regarding missing items and the absence of thorough documentation and communication contributed to the deficiency, resulting in unresolved grievances and dissatisfaction among residents.