Failure to Investigate and Document Grievance Resolution
Penalty
Summary
The facility failed to ensure that a grievance investigation and resolution were conducted and documented according to its own policy for one of three sampled residents. The facility's grievance policy requires that all grievances, including those made by family members, be promptly investigated and resolved, with documentation of the investigation and communication of the resolution to the complainant. In this case, a family member reported concerns regarding a resident's care, including dirty sheets, uncertainty about whether the resident had eaten, and the resident being found soaking wet and in the same clothing as the previous day. The complaint was recorded by the Social Services Director and forwarded to nursing and laundry, but there was no documentation of an investigation or resolution, nor evidence that the complainant was notified of any outcome. The resident involved had multiple diagnoses, including rheumatoid arthritis, type 2 diabetes, Alzheimer's disease, anxiety disorder, bipolar disorder, atherosclerotic heart disease, and mood disorder due to a physiological condition. The resident was rarely or never understood, as indicated by the MDS assessment. Despite the facility's policy outlining specific steps for grievance handling, including investigation and communication of findings, these steps were not followed or documented for the complaint in question. Interviews with the Director of Nursing and Social Services Director confirmed the lack of investigation and resolution documentation.