Failure to Provide Written Grievance Resolutions to Resident Representative
Penalty
Summary
The facility failed to provide written conclusions and resolutions of grievances reported by a responsible party for a resident with end-stage renal disease and diabetes mellitus, who was moderately cognitively impaired. According to the facility's own policy, the Grievance Official is required to issue a written decision to the resident or their representative at the conclusion of any grievance investigation, including details such as the date received, investigative steps, findings, confirmation status, corrective actions, and the date the decision was issued. However, for two grievances reported by the resident's responsible party—one regarding room cleanliness and wound treatment, and another concerning an unclean bathroom—investigation results and resolutions were only communicated verbally, with no written documentation provided to the responsible party as required. Interviews revealed that the responsible party felt the facility frequently failed to communicate regarding concerns about the resident's care, and that grievances submitted to Social Services did not receive written follow-up. The Director of Social Services confirmed that written grievance response letters had been discontinued after a certain point and was unaware of the federal requirement to provide written notification of grievance conclusions and resolutions. This lack of written communication constituted a failure to honor the resident's right to receive a written decision regarding grievances, as outlined in both facility policy and federal regulations.