Failure to Promptly Investigate and Resolve Resident Grievance
Penalty
Summary
A resident with multiple sclerosis and anxiety disorder, who was cognitively intact and responsible for their own healthcare decisions, repeatedly voiced concerns to staff and the Grievance Official about being woken up early in the morning by another resident's yelling. Despite the facility's policy requiring prompt efforts to resolve grievances, including documentation and investigation, the resident's complaint was not formally documented, investigated, or resolved. The Certified Nursing Assistant who received the complaint did not inform others or file a grievance, assuming other staff were aware. The Grievance Official acknowledged receiving the complaint and offering a room change, which the resident declined, but did not document the interaction or initiate a grievance process. Interviews with facility staff revealed uncertainty about when to file a grievance and inconsistent application of the grievance policy. The Social Worker, designated as the Grievance Official, admitted that a grievance should have been filed given the resident's continued distress. The Nursing Home Administrator also indicated that the process for filing grievances depended on the resident's level of upset and was unclear if the resident was offered the opportunity to file a formal grievance. As a result, the facility failed to make a prompt effort to investigate and resolve the resident's grievance as required by policy.