Failure to File Grievance After Resident Incident
Penalty
Summary
The facility failed to file a grievance for one resident after an incident involving a fall from a wheelchair on a van lift prior to the resident's scheduled dialysis. The facility's policy states that any resident, family member, or appointed representative may file a grievance or complaint regarding care, treatment, staff behavior, theft, or any other concerns, and that grievances may be submitted orally or in writing. Upon receipt, the grievance officer is required to review and investigate the allegations and submit a written report to the Administrator within five working days. However, review of the facility's grievance log showed no grievance was filed for this incident. The resident involved had multiple diagnoses, including end stage renal disease, dependence on renal dialysis, type 2 diabetes, and atrial fibrillation. The resident's representative reported being upset due to delayed notification about the fall and subsequently spoke in person with the DON about her concerns. The DON confirmed the conversation but denied filing a grievance, and the incident was not documented in the grievance log as required by facility policy.