Failure to Promptly Resolve and Communicate Grievance Regarding Missing Prosthetic Leg
Penalty
Summary
The facility failed to promptly resolve a resident's grievance regarding a missing prosthetic leg and did not keep the resident informed about the progress toward resolution. The resident reported the missing prosthetic leg to the facility in January, but there was no documentation in the medical record indicating that the facility had misplaced the prosthetic leg or had taken steps to address the grievance. The Ombudsman became involved after the resident received no updates from the facility and contacted the facility multiple times without receiving any information or solutions regarding the missing prosthetic leg. Interviews confirmed that the facility was aware of the missing prosthetic leg since an evacuation event in November, but no efforts were made to reimburse or replace the prosthetic leg until the resident returned from medical treatment several months later. Throughout this period, the resident and the Ombudsman did not receive updates or communication from the facility about the status of the grievance or any actions being taken to resolve it.