Failure to Investigate and Resolve Resident Grievances
Penalty
Summary
The facility failed to ensure that a resident's grievances and complaints were properly investigated and resolved. The resident, who was cognitively intact and had a history of anxiety, mood disorder, and a surgical wound, reported filing multiple grievances during her stay. She expressed that her complaints were not followed up on or resolved, particularly regarding inadequate pain management, with her pain consistently rated between 7 and 9 out of 10. Documentation showed that the resident's requests for pain medication were not always addressed promptly, and there were discrepancies in the records regarding the timing and administration of pain medication. Review of grievance forms revealed that the facility's documentation did not accurately reflect the events as described by the resident. For example, a grievance form indicated that the resident received her requested pain medication at 1:00 p.m., but records showed it was not administered until 3:01 p.m. Additionally, a dressing change for her surgical wound was not completed as required. The facility's investigation into these grievances was insufficient, lacking evidence of a thorough investigation or a clear resolution provided to the resident. Interviews with facility staff, including the DON and regional nurse consultant, confirmed that grievances were reviewed but did not result in appropriate follow-up or resolution. The facility's own grievance policy required that all complaints be investigated and a written summary provided, including steps taken and any corrective actions, but this process was not followed in the resident's case. The lack of proper investigation and resolution of the resident's grievances constitutes a deficiency in honoring the resident's right to voice grievances without discrimination or reprisal.