Failure to Promptly Resolve and Communicate Grievance Decision
Penalty
Summary
The facility failed to promptly resolve a grievance submitted by the family of a resident who was determined to lack capacity to understand her rights and responsibilities. The grievance, submitted by the resident's son and daughter, alleged unauthorized administration of a narcotic pain medication (Morphine) and included an accusation by a staff member that the family was abusing the resident by force-feeding and withholding pain medication. The family requested a detailed written explanation of the events, including vital signs, medication administration records, and hospital discharge documents. Although the facility's grievance policy required prompt investigation and communication of resolution, it did not specify the right to a written decision, and the family did not receive the requested written documentation or a thorough investigation into their concerns. Interviews with the family confirmed that they did not consider the grievance resolved, as they had not received the information they requested or a written response. The Grievance Officer and clinical manager were unaware of the regulatory requirement to provide written grievance decisions, and the facility did not investigate or report the abuse allegation to the appropriate authorities. The grievance was only reopened after the surveyor's inquiry, indicating that the facility did not follow its own policy or regulatory requirements regarding grievance resolution and communication.