Failure to Promptly Address and Resolve Resident Grievances
Penalty
Summary
A deficiency occurred when the facility failed to promptly address and resolve a resident's grievances regarding care and staff interactions. The resident, who was cognitively intact and dependent on staff for transfers, bed mobility, and toileting, reported to a nurse that certain evening shift employees spoke to them in a mean tone and acted independently without involving the resident. Despite these concerns being communicated, there was no documentation of grievances for this resident in the facility's grievance log, and the care plan did not reflect the resident's accusatory behaviors or interventions to address them. Nurses' notes over several days documented accusatory statements by the resident about staff and care, but these were not followed up with investigations or reported to the grievance officer as required by facility policy. Interviews with facility staff, including the Director of Nursing Services (DNS), LPN, and Social Worker (SW), revealed a lack of awareness and follow-up regarding the resident's repeated complaints. The DNS acknowledged that although the resident had previously reported complaints about staff behavior, no formal investigation was initiated, and nothing was documented. The SW, who served as the grievance officer, was unaware of the resident's ongoing concerns and stated that he would have followed up if informed. Facility policy required that all grievances be reported, investigated, and resolved in writing, but this process was not followed for the resident's repeated allegations, resulting in a failure to honor the resident's right to voice grievances without discrimination or reprisal.