Failure to Document, Investigate, and Resolve Resident Grievances
Penalty
Summary
The facility failed to ensure that a resident's grievances regarding missing personal items were promptly documented, investigated, tracked, and resolved. The resident, who was cognitively intact and admitted for long-term care with diagnoses including diabetes and hemiplegia, reported multiple missing clothing items following a recent hospitalization. Despite making multiple complaints and involving the local Ombudsman, there was no documentation of these grievances in the facility's grievance log, nor were concern forms completed. The resident expressed a lack of trust in facility staff due to previous experiences with former administration discarding his belongings without consent. Interviews with the Ombudsman and the current Nursing Home Administrator (NHA) revealed that meetings had taken place to address the missing items, but there was conflicting information regarding the resident's wishes for reimbursement or for staff to search his room. The NHA stated that no grievance was logged because the resident did not want to file a complaint, but the Ombudsman reported that the resident only objected to staff searching his room, not to reimbursement or searching laundry. By the end of the survey, there was no documentation provided to support the facility's claims, no evidence that the laundry had been searched, and no record of the meeting with the resident and Ombudsman.