Failure to Implement Grievance Policy for Resident Complaints
Penalty
Summary
The facility failed to implement its grievance policy for two residents who reported concerns regarding personal property and care. In the first instance, a long-term resident reported missing clothing to the Environmental Services Supervisor (EVS) and the resident's family also raised the issue. The EVS Supervisor acknowledged the concern but did not complete a grievance form or escalate the issue to the Director of Nursing or the Nursing Home Administrator, as required by facility policy. The Social Service Director confirmed that no grievance form was filed for this incident, and the most recent grievance form related to clothing was from several months prior, indicating the current concern was not documented or processed according to policy. In the second case, a newly admitted resident's family member reported that the resident was found in soiled clothing and an unkempt state two days after admission, despite having notified staff and meeting with several facility personnel about the issue. The family described the meeting as confrontational and did not receive any follow-up communication from the facility regarding their complaint. The Social Service Director and the designated Grievance Official both confirmed that no grievance was logged or investigated for this incident, and the Grievance Log contained no entries for the relevant period. Staff interviews revealed a lack of awareness and adherence to the grievance policy, with some staff admitting they had never read the policy. Facility policy requires that all grievances, whether verbal or written, be documented, investigated, and tracked, with written notice of the outcome provided to the complainant. In both cases, the facility did not follow these procedures, as grievances were not formally recorded, investigated, or communicated to the residents or their families. The Director of Nursing and the Nursing Home Administrator acknowledged that the grievance process was not followed and needed improvement.