Failure to Investigate and Resolve Resident Grievances
Penalty
Summary
The facility failed to properly investigate and resolve resident grievances related to missing personal property and care concerns for two residents. One resident, with a diagnosis of Alzheimer's disease and severe cognitive impairment, had multiple grievances submitted by their representative regarding missing personal items, including a blue blanket and a hoodie. Despite repeated communications and requests for written plans and updates, the facility's grievance forms lacked documentation of resolution, dates, and notification to the complainant. Interviews with staff revealed confusion about the process, lack of follow-up, and missing documentation, with the Director of Social Services unable to locate an initial grievance form and uncertain about whether written summaries were provided to complainants. Another resident, who was cognitively intact and had a history of cerebral infarction, diabetes, and adjustment disorder, submitted a grievance regarding care issues such as receiving regular showers, hair washing, therapy, laundry return, and timely assistance. The grievance form showed that only therapy services addressed the concerns, with no documented response from nursing or environmental services. The Director of Social Services and the Director of Nursing both acknowledged that the grievance was not fully resolved in a timely manner, and the Environmental Services Director stated he had not seen the grievance until much later. Facility policy required timely investigation and resolution of grievances, generally within five business days, but the documentation and interviews indicated that grievances were not consistently or thoroughly addressed. There was a lack of clear communication, follow-up, and documentation regarding the investigation and resolution of grievances, as well as notification to residents or their representatives about outcomes. These failures resulted in unresolved grievances and a lack of assurance that residents' rights to voice concerns without discrimination or reprisal were honored.