Failure to Follow Grievance Policy After Resident Reports Peer Antagonism
Penalty
Summary
The facility failed to follow its grievance policy and procedures when a resident voiced concerns about the treatment received from another resident. One resident, who was cognitively intact and able to express his needs, reported being antagonized and taunted by another resident with moderate cognitive impairment and a history of verbal behaviors directed toward others. The concerned resident reported these issues to both the social service designee (SSD) and a registered nurse, but no grievance was filed on his behalf, and he did not receive any documented resolution or follow-up. Staff interviews confirmed that the antagonistic behavior was known among staff, with the SSD acknowledging that the resident had voiced concerns and that the issue had been discussed with the interdisciplinary team. However, the SSD did not document the conversations or initiate a grievance form, and the assistant administrator confirmed that a grievance should have been filed for any resident concern. The facility's policy required prompt investigation and written resolution of grievances, but these steps were not taken in this case.