Failure to Document Grievance Resolutions
Penalty
Summary
The facility failed to properly document the resolution of grievances for four out of six residents, as required by its own grievance policy. The policy designates the Administrator as the Grievance Officer, responsible for overseeing the grievance process, tracking grievances to their conclusion, and issuing written decisions to residents. However, review of grievance forms revealed missing documentation in several key areas, including whether the grievance was resolved, the date of resolution, notification to the resident or representative, and the staff member who received the grievance. Specifically, grievances filed on behalf of multiple residents lacked information in the 'Resolution of Grievance/Concern' section, with some forms left entirely blank regarding resolution details. Interviews with the DON and Administrator in Training confirmed that the facility did not institute corrective actions or resolve the grievances for these residents. The lack of documentation and follow-through on the grievance process was identified through review of facility documents and staff interviews, indicating non-compliance with both facility policy and state regulations regarding management and resident rights.