Failure to Report and Document Resident Grievance Regarding X-ray Technician Conduct
Penalty
Summary
The facility failed to ensure that a resident's grievance was reported, investigated, and documented according to its established grievance policy. A resident, admitted with diagnoses including post-joint replacement aftercare, osteoarthritis, and type 2 diabetes, reported that a male x-ray technician entered her room late at night without knocking, did not introduce himself, and did not explain the procedure, causing her distress. The resident was cognitively intact and able to make decisions at the time of the incident. Despite the resident voicing her complaint to a CNA, the concern was not reported to licensed nursing staff, nor was it documented in the resident's records or on a grievance form. Interviews with facility staff confirmed that the complaint was not communicated to the appropriate personnel, and a review of facility policies indicated that all staff are required to report such grievances. The Director of Nursing acknowledged that the complaint was not addressed as required by policy, and that this failure could negatively affect the resident's mental health.