Failure to Document and Resolve Resident Grievance
Penalty
Summary
The facility failed to sufficiently act upon a grievance filed by a cognitively intact resident regarding an incident with a nursing assistant. The resident reported that a nursing assistant entered her room during an evening shift and attempted to change an incontinent brief, despite her not wearing them, and was unkind during the encounter. The resident reported the incident to staff the following morning and subsequently filed a grievance, requesting that the nursing assistant not return to her unit. However, there was no follow-up from the facility regarding the outcome of her grievance, and the nursing assistant continued to work on the unit. A review of the facility's grievance records and the resident's progress notes revealed no documentation of the incident or the grievance. Interviews with staff indicated that grievances should be documented, investigated, and resolved using both hard copy forms and an electronic system, but no record of the resident's grievance could be found. The administrator confirmed that the incident was known and addressed with the nursing assistant, but no written resolution or follow-up was provided to the resident, and the grievance form was missing. The facility's policy requires all grievances to be documented and retained for at least three years, which was not followed in this case.