Failure to File and Investigate Grievance for Resident's DPOA
Penalty
Summary
A deficiency was identified when the facility failed to file and investigate a grievance for one resident out of three reviewed for grievances. The issue arose when the resident's Durable Power of Attorney (DPOA) visited the facility and complained to the Director of Nursing (DON) about the resident being discharged and transferred to another facility without her approval or notification. The DPOA expressed significant dissatisfaction with the lack of communication regarding the discharge and expected the facility to address her concerns. Upon review, it was found that the DPOA held financial authority only, as indicated by the Durable Power of Attorney form. Despite this, the facility's policy clearly stated that any resident or anyone acting on their behalf could file a grievance, and staff were required to assist in filing and investigating such grievances. The DON acknowledged the DPOA's complaint and passed it to the Social Service Director for follow-up, but no documentation was found to show that the complaint was investigated or that the DPOA was informed of any outcome. The Social Services Assistant confirmed that no investigation or resolution was pursued, and the DPOA was not communicated with regarding the complaint. Interviews with facility leadership, including the DON, Social Services Assistant, and Nursing Home Administrator (NHA), revealed a misunderstanding or misapplication of the facility's grievance policy. The NHA believed that the financial-only DPOA was not acting on the resident's behalf in a medical capacity and therefore did not warrant follow-up. However, both the DON and Social Services Assistant later confirmed that the DPOA's complaint should have been treated as a valid grievance according to facility policy, but it was not filed, investigated, or resolved as required.
Plan Of Correction
1. On , a grievance was initiated by the Social Service assistant for resident #1 regarding the resident's fiduciary DPOA concern regarding resident #1 being discharged to another center without their knowledge. A final resolution was delivered to the fiduciary DPOA on . 2. By an audit of current residents was completed by the Social Service Manager to ensure any resident with power of attorney is clarified on the sheet to ensure proper notification of any discharge plans. On the Director of Nursing was re-educated by the NHA to ensure any concerns are brought to the interdisciplinary team as a grievance and a conclusion/resolution is brought to the person filing the grievance. By staff were re-educated on the Grievance process by the Staff development coordinator. 3. Random interviews of residents/family/visitors 3 times a week for 12 weeks to ensure all concerns are brought through the grievance process. Interviews to be conducted by social services. 4. Interviews will be brought to the Quality Assurance and Assessment/Quality Assurance Performance Improvement committee for a minimum of three months or until substantial compliance is achieved.