Failure to Promptly Address Resident Grievance Regarding Missing Personal Items
Penalty
Summary
The facility failed to promptly address a grievance reported by the representative of a resident with dementia, atherosclerotic heart disease, and chronic kidney disease. The resident, who required varying levels of assistance with daily activities and did not have the capacity to make decisions, was discharged home, at which point her representative reported missing clothing items to the Social Service Assistant (SSA). Despite being informed of the missing items, the SSA did not initiate a grievance report or follow up with the representative, and no entry was made in the facility's grievance log. The SSA acknowledged that a grievance report should have been initiated and that failing to do so was a violation of the resident's rights. Further interviews with the Director of Nursing (DON) and the Administrator confirmed that they were not informed of the grievance and that the facility's policy required prompt initiation and resolution of grievances. The facility's policies also stipulated that all grievances should be responded to in writing, with actions and rationale documented. The lack of prompt response and failure to follow established grievance procedures resulted in a delay in investigating the missing clothing and violated the resident's right to have grievances addressed without discrimination or reprisal.