Failure to Resolve and Document Resident Grievances
Penalty
Summary
The facility failed to resolve and document grievances in a timely and complete manner for two residents. For one resident with a history of stroke and hemiplegia, a concern was raised regarding a malfunctioning personal wheelchair. The concern was reported by both the resident and a family member, and a concern form was completed. However, the facility did not ensure that the wheelchair manufacturer's representative was contacted for repairs, and the follow-up documentation was incomplete, lacking confirmation of the resident's satisfaction or the resolution of the issue. Multiple staff members, including the Social Services Director, Maintenance Director, Rehabilitation Director, and Administrator, were either unaware of the concern or did not take action to resolve it, despite the issue being discussed in a morning meeting. For another resident with cerebral palsy, heart failure, and COPD, multiple concerns were raised regarding care, including not receiving medications on time, inadequate incontinence care, and issues with supplies and staff responsiveness. These concerns were communicated verbally to various staff members, including nurse aides and management, but were not consistently documented or reported according to facility policy. Staff interviews revealed that concerns were often not written down or formally reported, with some staff assuming that management was already aware due to the resident's frequent complaints. The Social Services Director, Assistant Director of Nursing, and Director of Nursing all confirmed they were not aware of these ongoing concerns and that there was no documentation to support that the grievances had been addressed or resolved. The facility's grievance policy required prompt resolution and documentation of all grievances, whether verbal or written, typically within five business days. In both cases, the facility failed to follow its own policy by not ensuring timely resolution, proper documentation, and feedback to the residents regarding their concerns. This resulted in unresolved grievances and a lack of accountability in addressing resident complaints.