Failure to Investigate Resident Grievance Regarding Staff Conduct
Penalty
Summary
The facility failed to conduct a thorough investigation into a resident's grievance regarding the actions and behaviors of a specific LPN. The resident, who had a history of cerebral vascular accident with right side hemiplegia and diabetes, submitted a grievance form detailing multiple incidents over the course of a year. These included the LPN preparing the wrong insulin, making upsetting comments, and engaging in behaviors perceived as passive-aggressive or intended to distress the resident. The resident also reported that the LPN made statements about her hallucinating and expressed a desire not to have this LPN involved in her care. Upon review, it was found that the facility's investigation did not include documentation addressing the resident's specific concerns about the LPN's conduct, nor was there evidence that a statement was obtained from the LPN in question. The facility's grievance policy required a thorough investigation with supporting documentation, but these steps were not completed or recorded in this case. The DON confirmed the absence of documented evidence addressing the resident's concerns or obtaining a statement from the LPN.