Failure to Follow Grievance Policy and Resolve Resident Complaint
Penalty
Summary
The facility failed to follow its grievance policy and maintain an effective process for residents to voice and resolve grievances. A resident, who was cognitively intact and had upper extremity impairment, anemia, and renal insufficiency, reported that a CNA treated them roughly during a transfer to the restroom, resulting in pain and injury. The resident stated that the CNA insisted they stand up despite their request for a lift, stomped on their feet, and pushed them onto the toilet, causing the resident to fall back and hurt their back. The resident reported the incident to multiple staff members, including nurses and the administrator, but did not receive timely feedback or resolution regarding their complaint. The facility's grievance log did not document the resident's complaint, and the investigation report lacked essential information such as the date and time the grievance was received, a summary of findings, and whether the grievance was confirmed. There was no written account from the resident included in the investigation, and no documentation of steps taken to prevent further violations during the investigation. The facility also failed to provide the resident with a summary of the findings or inform them of any corrective actions taken. The resident was not asked if they were satisfied with the outcome, and there was no documentation of their right to appeal the results. Interviews with staff revealed inconsistencies in the handling of the grievance. The ADON and Social Service Director acknowledged the resident's concerns but did not ensure proper follow-up or documentation. The CNA involved was removed from the resident's floor but continued to work in the facility, and there was no evidence of required training or disciplinary action being documented. The resident continued to experience pain and felt that their concerns were not addressed, expressing frustration at the lack of communication and resolution.