Failure to Log and Document Resident Grievances
Penalty
Summary
The facility failed to follow its own grievance policy regarding the documentation and logging of grievances for one resident. According to the facility's policy, when a concern or grievance is brought forward by staff, family, responsible party, or resident, a concern form should be completed and submitted to the Social Services Director or Administrator, who is then responsible for logging the concern into a grievance log. The policy also requires that the results of grievances be maintained for a minimum of three years. In the case of one resident, the quarterly Minimum Data Set (MDS) assessment indicated that the resident was able to understand and be understood by others. Two separate grievances were documented: one involving the resident's daughter finding the resident soiled with a bowel movement and without a brief, and another involving the discovery of pills in a medication cup, in the resident's bed, and on the floor. Both incidents were reported to staff and the Director of Nursing, and immediate actions were taken to address the resident's condition and to notify staff. Despite the completion of grievance forms for both incidents, a review of the facility's grievance/complaint logs revealed that neither of these concerns was entered into the official log as required by policy. This was confirmed by the Director of Nursing, who acknowledged that there was no documented evidence of these grievances being logged. The failure to document and log these grievances constitutes noncompliance with both facility policy and federal regulations regarding the handling of resident grievances.
Plan Of Correction
Facility's new Social Services Director immediately completed facility grievance/complaint concern forms for the June 14th and June 15th grievances regarding Resident 13 and placed both concerns onto the June 2025 Grievance/Concern and Complaint Log. Any resident admitted to the facility has the ability to be affected by this alleged deficient practice. A whole house audit was completed to ensure recent grievances/complaints and/or concerns were placed onto the monthly Grievance/Concern and Complaint Log, and a grievance/complaint concern form was completed for the grievance. Nursing Home Administrator educated the new Social Services Director on the facility Concern/Grievance Policy and the facility grievance/complaint concern form. Nursing Home Administrator/designee will randomly audit the monthly Grievance/Concern and Complaint Log weekly times four weeks and then monthly times three months, and then reviewed by the Quality Assurance Performance Improvement Committee for results, areas of improvement, and/or continuation of audits. Results of these audits will be reviewed in Quality Assurance and Performance Improvement times four months or until substantial compliance is noted.