Failure to Follow Grievance Policy and Ensure Follow-Up on Care Concerns
Penalty
Summary
The facility failed to follow its grievance policy and did not ensure proper follow-up on care concerns raised by a resident and the resident's family. The resident, who had diagnoses including Parkinson's disease and a rib fracture, had multiple care concerns communicated via email by their family to the Admission's Director. These concerns included a missing back brace, discarded personal items, delayed follow-up after a fall, cleanliness of the resident's room, and issues with care assistance. The Admission's Director forwarded the email to other staff members, including the Social Service Director (SSD), Director of Nursing (DON), Executive Director (ED), and physical therapy, but did not formally document or file the grievance as required by facility policy. Interviews with facility staff revealed confusion regarding responsibility for filing grievances. The DON indicated that social services were responsible for filing grievances, while the SSD believed the Admission's Director was handling the concerns. The SSD stated that whoever received the grievance was typically responsible for documenting it and then submitting it to her for filing. Despite this, no formal grievance was filed, and the required investigation and written report were not completed within the specified timeframe outlined in the facility's grievance policy.