Failure to Investigate and Resolve Resident Grievances Regarding Missing Personal Items
Penalty
Summary
The facility failed to ensure that grievances raised by residents were thoroughly investigated and resolved, as required by policy. For one resident, who was cognitively intact, multiple personal items including an Amazon Tablet were reported missing. The grievance log documented the concern but concluded it was resolved because the resident was uncertain about owning the tablet and it was not listed on the inventory. However, there was no evidence that staff attempted to verify whether the resident ever had the tablet or if the inventory was accurate. Further review revealed that the resident's inventory was missing from the designated binder, and the available documentation was incomplete, lacking identifiers and dates. Observation confirmed the resident possessed several items not listed on the inventory, and staff acknowledged that inventory records were not always reliable. Another cognitively intact resident reported a missing iPhone and expressed dissatisfaction with having to replace it with an android phone. The grievance log showed that the facility documented communication with the resident's family, who declined a replacement phone, but there was no follow-up with the resident regarding the outcome of the grievance. Staff confirmed that no direct follow-up occurred. These failures to maintain accurate inventories and to follow up with residents about their grievances resulted in unresolved concerns and incomplete grievance investigations.