Failure to Document Grievance Outcome and Resident Satisfaction
Penalty
Summary
The facility failed to follow its established grievance process for a resident who was cognitively intact and had a history of hemiplegia, hemiparesis, contracture of the right hand, congestive heart failure, and type 2 diabetes. The resident submitted two grievances regarding the demeanor and response time of a CNA, specifically noting issues with the CNA's tone of voice, raised voice, and delay in responding to call lights. The first grievance was documented with findings and communication of the outcome to the resident. However, for the second grievance, while corrective action was taken regarding the CNA's assignment, the facility did not document the outcome of the grievance or whether the resident was satisfied with the resolution. The grievance form for the second complaint was left incomplete, with the outcome section and satisfaction question unanswered, despite being signed by both the Social Services Director and the Administrator. Interviews confirmed that the Social Services Assistant received and discussed the grievance with the resident, but there was no documentation of follow-up or clarification with the resident regarding the resolution. The Administrator acknowledged the lack of documentation and that clarification should have been sought to determine if the grievance met criteria for a reportable event. The facility's policy requires a response to grievances within a reasonable time, which was not met in this instance.