Failure to Resolve Resident Grievance Regarding Missing Personal Items
Penalty
Summary
The facility failed to maintain an effective grievance system as evidenced by its handling of a complaint regarding missing clothing for a resident. The resident, who was assessed to have intact cognitive function with a BIMS score of 14 out of 15, reported missing four pairs of sweatpants and stated that facility staff had not taken any action after being informed. The Director of Nursing (DON) acknowledged being aware of the complaint and documented the grievance, noting the specific items missing and that some clothing had been found while others remained unaccounted for. However, the section of the grievance form designated for resolution was left blank, and there was no documented resolution within the facility's stated timeframe for resolving grievances. Interviews with facility staff revealed a lack of clarity and follow-through in the grievance process. The Social Worker described her role as collecting grievances and distributing them to the appropriate staff, but indicated that missing items concerns were directed to the Administrator. Despite the facility's policy requiring grievances to be resolved within a reasonable timeframe, generally within five business days, the complaint regarding the missing clothing remained unresolved at the time of the survey. The Administrator confirmed that the grievance had not been resolved and acknowledged the need for process improvement.