Failure to Provide Written Notification of Grievance Outcomes
Penalty
Summary
The facility failed to notify residents and their representatives of the results of grievance investigations and any corrective measures taken, as required by its own policy. Record review and interviews revealed that for three cognitively intact residents who filed multiple grievances, there was no documentation that they received written notification of the investigation outcomes or the decisions made regarding their concerns. The grievance forms often lacked completion in sections related to outcome expectations, actions taken, and resolution, with only the Administrator's signature present. One resident filed a grievance about staff not assisting her to the bathroom after answering her call bell. The investigation led to staff retraining, but there was no documentation that the resident was informed of the outcome, either verbally or in writing. Another resident filed grievances regarding improper administration of eye drops and the presence of ants in his room. Investigations were conducted, and actions such as staff training and room cleaning were taken, but again, there was no evidence that the resident was notified of the results. A third resident filed several grievances, including concerns about missed insulin doses, room temperature, and improper glove use by staff. The investigations were completed, but the forms were incomplete, and there was no documentation of notification to the resident. Interviews with staff and administration confirmed that grievance outcomes were typically communicated verbally, and written responses were only provided upon request. The Administrator was unaware of the requirement for written documentation of grievance outcomes.