Failure to Document and Resolve Resident Grievances per Policy
Penalty
Summary
The facility failed to maintain proper documentation of resident grievances as required by its own policy and federal regulations. Six sampled grievances were reviewed, and none met the documentation requirements for recording the grievance decision. The facility's policy designates the Administrator as the Grievance Official and outlines responsibilities for tracking, investigating, and issuing written decisions regarding grievances, as well as maintaining a grievance log for three years. However, the facility did not follow these procedures, and the required documentation was incomplete or missing for all reviewed grievances. Specific examples include incomplete Concern Forms for multiple grievances reported by two residents and a family member. For instance, one resident reported issues such as mold and water damage, insufficient CNA staffing during night shifts, and missing personal items. The forms lacked documentation of immediate actions taken, investigation, follow-up, or resolution, and did not indicate whether the resident was satisfied with the outcome. Another family member reported concerns about resident care, therapy communication, and food quality, but the forms again lacked documentation of satisfaction, follow-up, or final resolution. During interviews, the Administrator confirmed that the facility did not have a Social Services Director at the time and acknowledged that grievance documentation and the grievance log were not kept up to date. The Administrator stated that some follow-up actions were taken, such as referring maintenance issues and reviewing staffing schedules, but these actions were not documented as required. As a result, it was unclear what actions had been taken in response to grievances and whether residents or their representatives were satisfied with the outcomes.