Failure to Maintain Effective Grievance Resolution Process
Penalty
Summary
The facility failed to maintain an effective grievance resolution process, as evidenced by the lack of prompt and documented responses to resident concerns. One resident, who was cognitively intact, reported multiple instances of missing personal items, including clothing, a purse, a wallet, a significant amount of money, and a blanket. The resident stated that she had reported these issues to both a staff member and the Administrator, but did not receive any follow-up or information regarding what actions, if any, were taken to address her concerns. The Administrator confirmed that unless a formal grievance form was completed, concerns were not documented or formally investigated, and no records existed of any investigation or follow-up for this resident's reported missing items. Additionally, during a group interview with eight residents who attended resident council meetings, seven expressed ongoing dissatisfaction with the facility's handling of laundry, specifically regarding the return of their clothing. Residents reported that labeled clothing often did not return from laundry, and issues persisted for a long time without resolution or explanation from the facility. Residents also indicated a lack of clarity and confidence in the grievance process, with some stating that expressing concerns did not lead to resolution and that there was confusion about how to file grievances. A review of the facility's grievance policy revealed that all grievances, whether expressed orally or in writing, should be tracked, investigated, and resolved, with the resident kept informed of progress. The policy also required the Grievance Officer to maintain a log of all grievances. However, the facility's practice, as described by the Administrator, was to only document and investigate concerns if a formal grievance was filed, resulting in a lack of documentation, tracking, and resolution for concerns that were not formally submitted. This practice did not align with the facility's written policy and led to unresolved resident grievances.