Failure to Document and Investigate Resident Grievance of Neglect
Penalty
Summary
The facility failed to properly document and process a resident grievance related to an allegation of neglect. Specifically, a resident reported that facility staff allowed her to remain on the floor for an hour after a fall. The facility's grievance log for the relevant month did not contain documentation of the date the grievance was received, a summary of the resident's allegation, steps taken to investigate, a summary of findings or conclusions, whether the grievance was substantiated, corrective actions implemented, or the date a written decision was issued. A review of the facility's grievance policy indicated that the Grievance Officer is required to submit a written report of findings to the Administrator upon receiving a grievance. However, interviews and document reviews confirmed that the facility did not follow this process for the resident's allegation. The Administrator in Training acknowledged that the required documentation and investigation steps were not completed or recorded in the grievance log.