Failure to Provide Grievance Official Information and Written Grievance Outcomes
Penalty
Summary
The facility failed to provide residents and their representatives with the name and contact information of the grievance official, and did not inform them of their right to receive the findings of grievance investigations and conclusions in writing. Policy documents and the admission handbook only referenced oral communication of findings and did not include the required written notification or the grievance official's contact details. During a walkthrough, no posting of the grievance official's name and contact information was observed in the facility. Additionally, review of three resident grievance reports revealed that findings, conclusions, and corrective actions were not documented. In one case, a resident's family reported an incident involving someone entering the resident's bed at night, but the internal investigation summary and follow-up were missing. Another resident complained about staff responsiveness and behavior, but the facility did not document the internal investigation or any actions taken. In a third case, a family member reported concerns about a CNA being too rough, but the investigation summary, corrective action, and communication to the family were not documented in the report.