Failure to Log, Investigate, and Resolve Resident Grievances
Penalty
Summary
The facility failed to establish and maintain an effective grievance system to ensure that residents' verbal concerns were initiated, logged, addressed, and resolved in a timely manner. Review of resident council meeting minutes over several months revealed that multiple grievances, such as requests for fresh fruit, complaints about food temperature, and concerns about call light response times, were repeatedly raised by residents but not documented or followed up through the facility's grievance process. The facility's grievance log did not contain any entries corresponding to these concerns, despite their documentation in meeting minutes and repeated verbal reports by residents. Interviews with residents indicated that they were unsure of the grievance process, with some expressing fear of retaliation or uncertainty about how to file a grievance. Several residents reported missing personal items, unresolved maintenance issues, and dietary concerns, none of which were formally logged or investigated according to facility policy. Staff interviews revealed inconsistent understanding and application of the grievance process, with some staff unaware of the need to complete grievance forms or believing that informal resolution was sufficient. The facility's policy required all grievances to be documented, investigated, and resolved with written communication to the resident, but this was not consistently followed. Specific examples included residents reporting missing belongings, unresolved maintenance requests such as a non-functioning television, and dietary issues like inappropriate snacks for a pureed diet. Staff responses varied, with some attempting informal resolution and others unaware of the concerns until prompted by surveyors. The lack of a systematic approach to logging and addressing grievances prevented the facility from identifying care trends and evaluating the effectiveness of any actions taken, resulting in residents repeatedly voicing the same issues without resolution.