Failure to Properly Investigate and Resolve Resident Grievance
Penalty
Summary
A deficiency occurred when the facility failed to properly address and resolve a grievance submitted on behalf of a resident who was dependent on staff for mobility due to multiple fractures and hemiplegia. The resident, who was cognitively intact, reported that a CNA refused to transfer them from a wheelchair to bed, citing the request was too close to shift change, resulting in the resident waiting an hour for assistance. The grievance documentation was incomplete, lacking a clear resolution and missing required signatures from the grievance official, DON, and NHA. Further investigation revealed that the social worker responsible for handling the grievance could not recall the details of the incident, was unable to locate additional information, and did not have statements from the CNA involved. There was no evidence that the CNA was interviewed or that the results of the grievance resolution were communicated to the resident or the NHA. The facility's policy required immediate attempts to resolve complaints, escalation if unresolved, and thorough investigation, including interviews with involved staff, none of which were documented in this case.