Failure to Initiate and Document Resident Grievances
Penalty
Summary
The facility failed to initiate and document resident grievances for two of five sampled residents, despite having a policy requiring all concerns to be logged and addressed within five days. For one resident, who was cognitively intact and required significant assistance with activities of daily living due to COPD, the family member reported concerns about the resident's unresponsiveness and staff's dismissive behavior when they sought help. The family member attempted to file a grievance regarding both the care provided and the staff's conduct but found no formal process in place. The administrator and director of nursing acknowledged the incident but did not document it as a grievance or log it, as required by facility policy. Another resident, also cognitively intact and medically complex, reported the loss of personal property (reading glasses) to a nursing assistant shortly after admission. The item was not replaced, and the resident was unfamiliar with the grievance process. Staff interviews revealed inconsistent practices regarding the documentation and handling of missing items, with some staff indicating that grievances should be logged and others stating that missing items were tracked separately. The administrator confirmed that the missing glasses were not logged and that no formal grievance process was initiated for this concern. The facility's failure to follow its own grievance policy resulted in concerns and complaints from residents and their representatives not being formally recognized, tracked, or resolved through the established process. This lack of documentation and follow-through denied residents and their families the opportunity for timely resolution of their grievances, as required by facility policy and regulatory standards.