Failure to Investigate and Document Family Grievance
Penalty
Summary
The facility failed to thoroughly investigate and document a grievance voiced by a resident's family member regarding concerns about the care provided. The family member reported being unable to reach the Nursing Home Administrator (NHA) by phone and communicated concerns via text message, but described the NHA as dismissive. The family member stated that after raising concerns, she did not receive any follow-up or information about what actions, if any, were taken by the facility. Review of the resident's medical records showed the resident had diagnoses including a wedge compression fracture of the vertebra and depression, and was admitted and later discharged from the facility within the review period. Interviews with facility staff, including the Social Services Director and the NHA, revealed that no grievance was documented or investigated regarding the family member's concerns, despite facility policy requiring all concerns to be treated as grievances and properly documented. The grievance logs for the relevant month contained no entries related to the resident in question. The NHA acknowledged receiving the concern but did not file a grievance or document any investigation, stating that a concern is not considered a grievance unless it occurs more than once, which is inconsistent with the facility's written grievance policy.