Failure to Properly Address and Resolve Resident Grievance
Penalty
Summary
A deficiency occurred when the facility failed to properly address and resolve a resident's grievance in accordance with its own policies and procedures. The resident reported sustaining a skin abrasion to her thigh after a CNA changed her soiled adult brief, alleging that the CNA was too rough and hard with the towel during cleaning. The resident initially reported this incident to facility staff and later reiterated her concern during a resident council meeting, stating that the facility had not followed up with her or addressed her specific concern. The facility's grievance official, the Social Services Designee (SSD), documented the initial grievance on the facility's grievance form but failed to include the resident's specific allegation that the CNA was not gentle and cleaned her hard. The SSD acknowledged that this information should have been documented and addressed, and that a determination should have been made as to whether the resident was satisfied with the investigation and outcomes. The grievance form sections regarding the resident's satisfaction and the date the grievance was resolved were left blank. Further, when the resident raised her concern again during a resident council meeting, the facility documented the concern but the department's written response only addressed whether the resident would be compensated for the skin tear, not the allegation of rough handling. The section on the form indicating whether the allegation was resolved to the resident's satisfaction was also left blank. These failures resulted in the resident's grievance not being thoroughly addressed, investigated, documented, or resolved as required by facility policy.
Plan Of Correction
F-585 Grievance Corrective Action Initiated For Resident/s On 6/18/25, the Social Services Director (SSD) met with Resident 53 to follow up on her grievance, documented her concerns in full, and ensured her satisfaction with the facility's investigation and action. On 6/18/25, Resident 53's grievance form was immediately updated to include the omitted allegation regarding the CNA being too rough and a documented resolution, including whether the resident was satisfied. How Potential Other Residents Were Identified and Corrective Action Taken On 6/25/25, the SSD initiated a review of all active grievance logs from the past 30 days to ensure complete documentation, follow-up, and resident satisfaction were recorded appropriately. No other unresolved grievances were identified. Measures/Systemic Changes Initiated to Prevent Future Recurrence On 7/10/25, the DON/designee re-educated facility staff - IDT (Social services, activities, and DSD), including CNAs and Licensed nurses, on the grievance reporting process, emphasizing the importance of thorough documentation and prompt follow-up per the facility's P&P. The grievance tracking tool will be checked by the social services director to ensure all grievances include: Full resident concern details, steps taken to investigate, final determination and corrective actions, confirmation of resident satisfaction, and resolution date. The Administrator will review all grievances on a weekly basis for follow-up and resolution on a timely basis. Resident Council agendas will now include a follow-up item to verify that concerns voiced are addressed and documented thoroughly by department heads and verified by the administrator on a monthly basis. Monitoring Plans to Ensure Solutions are Achieved and Integrated into QA System The SSD will provide a summary trend analysis of the findings to the facility's monthly QAPI Committee for 3 months or until such time as consistent substantial compliance has been achieved, as determined by the committee. Date of Compliance: 6/25/25 The Administrator will review all grievances weekly for follow-up and resolution on a timely basis. Resident Council agendas will include a follow-up item to verify that concerns voiced are addressed and documented thoroughly by department heads and verified by the administrator on a monthly basis. Monitoring Plans to Ensure Solutions are Achieved and Integrated into QA System The SSD will provide a summary trend analysis of the findings to the facility's monthly QAPI Committee for 3 months or until such time as consistent substantial compliance has been achieved, as determined by the committee. Date of Compliance: 6/25/25