Failure to Investigate and Resolve Resident Grievances per Policy
Penalty
Summary
The facility failed to conduct thorough investigations and provide appropriate resolutions for grievances submitted by two residents. According to the facility's grievance policy, all concerns and grievances must be investigated, documented, and followed up on, with written resolutions provided to the residents. However, review of grievance forms for two residents showed that the forms lacked documentation of investigations, outcomes, or notifications to the residents regarding the resolution of their grievances. One resident reported missing personal items and concerns about her roommate, but there was no evidence of investigation or communication of results. Another resident submitted a grievance, but the form did not indicate whether it was investigated or resolved, nor if the resident was informed of the outcome. Interviews with staff revealed that concerns voiced by residents were often handled informally and not always documented as formal grievances. The Social Services Director acknowledged that she did not always treat resident concerns as formal grievances and did not consistently investigate or resolve them. The LPN and DON both indicated that residents were encouraged to fill out their own grievance forms, and staff would only assist if the resident was unable to do so. The Administrator confirmed that if residents chose not to fill out a grievance form, staff would attempt to resolve the issue informally, rather than following the formal grievance process. Both residents involved were cognitively intact, as indicated by their BIMS scores, and were able to clearly recall events and express their concerns. Despite this, they reported not receiving any feedback or resolution regarding their grievances. The facility's grievance logs showed that grievances were being submitted and investigated, but the specific grievances for these two residents lacked documentation of investigation, outcome, or communication, indicating a failure to follow the facility's established grievance policy.