Failure to Address Resident Grievance Regarding Missing Personal Property
Penalty
Summary
The facility failed to ensure that a resident's right to file a grievance and have it promptly addressed was honored, as required by facility policy and regulation. A resident with diagnoses including heart failure, chronic kidney disease, and lymphedema reported missing personal property, including a bag containing a license, gift cards, cash, and multiple clothing items. The resident stated that new clothing purchases were not recorded on the inventory sheet and that, despite having receipts for the missing items, they had not been offered a grievance form or seen the Social Worker or Administration regarding the missing property. The resident only discussed the issue with housekeeping staff, who did not escalate the matter or initiate a formal grievance process. Interviews with staff revealed inconsistencies and gaps in the facility's process for handling missing items and grievances. The Director of Housekeeping acknowledged repeated discussions with the resident about missing items and attempts to contact the outside launderer but did not notify the Social Worker or initiate a grievance. The Director of Social Work and the Administrator both indicated that they were unaware of the missing items and described unclear or incomplete procedures for investigating and resolving such complaints, particularly when items were not listed on the inventory form. Staff interviews also revealed confusion about documentation, notification responsibilities, and the process for reimbursement or investigation when items were missing. Documentation review confirmed that the facility's policies required prompt investigation and resolution of grievances, including written summaries and communication of outcomes to residents. However, there was no documented evidence that a grievance was filed, an investigation was conducted, or the issue was resolved for the resident's missing property. The lack of coordination among staff and failure to follow established grievance and missing item procedures resulted in the resident's complaint not being formally addressed or resolved.