Failure to Address and Resolve Resident Grievances
Penalty
Summary
The facility failed to ensure that resident grievances were properly addressed and resolved, as required by their grievance policy. Review of the policy indicated that the social services director was designated as the Grievance Official, and staff were expected to document grievances and provide written decisions at the conclusion of investigations. However, during resident council meetings in February and March, residents raised concerns about garbage not being emptied, delays in room painting, and requests for assistance with room organization, but there was no documentation of resolution for these issues. The Activity Director stated that grievances from resident council meetings were sometimes handled informally, such as by writing notes to maintenance, rather than following the formal grievance process. For individual residents, the facility did not follow the grievance process as outlined. One resident reported a missing blanket to their nursing aide and a collateral contact, but no grievance form was completed, and the issue was not entered into the grievance log. The administrator confirmed that no grievance had been filed for this incident. The nursing aide involved stated that a grievance form would only be completed if the resident was upset or needed the item replaced immediately, which is not consistent with the facility's policy. Another resident complained during a resident council meeting about not receiving a shower for four weeks. Although a grievance form was completed and indicated that a shower would be provided the next day, electronic health records showed that the resident did not receive a shower until seven days later. The DON confirmed that the resident should not have had to wait that long for a shower. These failures resulted in residents repeatedly reporting the same care issues without resolution.