Failure to File and Investigate Grievance for Resident's DPOA Complaint
Penalty
Summary
The facility failed to file and investigate a grievance for one resident out of three reviewed, as required by both state statute and the facility's own grievance policy. The policy mandates that any grievance, whether submitted orally or in writing by a resident or anyone acting on their behalf, must be documented, investigated, and communicated back to the complainant. In this case, the resident's Durable Power of Attorney (DPOA) visited the facility and expressed dissatisfaction to the DON regarding the resident's discharge and transfer without her approval or notification. The DPOA reported feeling upset and believed the facility should have communicated with her about the discharge. Upon review, it was found that the DPOA held financial authority only, as indicated by the Durable Power of Attorney form. Despite this, the DON acknowledged the DPOA's complaint and noted it, intending to pass it to the Social Service Director for follow-up per policy. However, the facility's grievance logs did not show any record of a grievance being filed or investigated regarding this complaint. Interviews with the DON, Social Services Assistant, and Nursing Home Administrator confirmed that no documentation existed to show the complaint was addressed, investigated, or communicated back to the DPOA. The Nursing Home Administrator stated that the facility's policy only required grievances to be filed by residents or those acting on their behalf, and after assessment, determined the financial DPOA was not acting on the resident's behalf in this context. However, both the DON and Social Services Assistant later confirmed that the DPOA had a valid complaint that should have been processed as a grievance. The facility did not investigate, resolve, or communicate the outcome of the complaint, resulting in noncompliance with statutory and policy requirements for grievance handling.
Plan Of Correction
N 042 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.