Failure to Investigate and Resolve Resident Grievances
Penalty
Summary
The facility failed to ensure that resident grievances were properly investigated and that determinations or resolutions were provided to residents. Interviews and document reviews revealed that issues raised during Resident Council Meetings were not consistently entered into the grievance program, and there was no documentation of investigations or resolutions for the grievances. The Social Worker stated that not all new staff had access to the computer system to input investigations and resolutions, resulting in a lack of follow-up on reported concerns. The Director of Nursing confirmed the absence of documentation for grievance investigations and resolutions, despite being able to provide meeting agendas where related topics were discussed. Resident Council Meeting Minutes and grievance logs from January through March documented multiple unresolved issues, including staff not performing rounds every two hours, staff being rude or sleeping during shifts, delayed medication administration, call lights not being answered for extended periods, and personal items being taken from residents' rooms. The facility was unable to provide evidence of steps taken to investigate these grievances, summaries of findings, confirmation of grievances, or corrective actions taken, as required by their own grievance policy.