Failure to File and Track Grievance Related to Alleged Abuse/Neglect
Penalty
Summary
The facility failed to ensure that a grievance regarding alleged abuse or neglect was properly filed, tracked, and promptly resolved for one resident. According to the facility's own policy, upon receipt of a grievance or complaint, the grievance officer is required to review and investigate the allegations, submit a written report to the administrator within five working days, and coordinate actions with appropriate agencies as necessary. However, review of the facility's grievance log for the relevant months showed no entry for the resident's grievance in April, despite a Grievance Form being filled out for a reportable incident. The social worker responsible for the grievance log admitted that the incident was not added to the log and also stated she was unaware of the facility's grievance policy during her employment. Further, the social worker explained that she was covering for another staff member on leave and that both she and the absent employee were responsible for the grievance log. The administrator, when asked, was unable to provide knowledge of a grievance policy beyond what was included in the admissions packet. The social worker became aware of the situation during a clinical meeting and conducted an interview with the resident involved, but did not interview other residents associated with the alleged perpetrator, as they were deemed non-interviewable. These actions and omissions resulted in the facility not following its own grievance procedures and failing to document and resolve the grievance as required.