Failure to Address and Investigate Resident Grievances Regarding Nursing Care
Penalty
Summary
The facility failed to act upon, investigate, or resolve a resident's complaints regarding nursing care. The resident, who had intact cognition and multiple medical diagnoses including heart failure, Parkinson's Disease, and chronic kidney disease, was dependent on staff for most activities of daily living. The resident reported that staff frequently turned off her call light without providing assistance, and that she was repeatedly double briefed with two incontinent products at night despite expressing her objection. She also reported discomfort with a particular staff member assisting with her care. These concerns were communicated to various staff members, including floor staff, a nurse manager, and therapy staff. Despite these complaints, there was no documentation in the resident's progress notes indicating that her concerns were acted upon, investigated, or resolved. The facility's grievance log only contained a grievance related to spiritual care, not the care concerns raised by the resident. Interviews with staff revealed a lack of awareness or follow-up regarding the resident's specific complaints about double briefing and staff assignments. The facility's grievance policy required that all grievances be thoroughly investigated, tracked, and resolved, but this process was not followed in the resident's case.