Failure to Document and Resolve Family Grievance Regarding Resident Care
Penalty
Summary
Facility staff failed to demonstrate efforts to resolve a written grievance submitted by a resident's responsible party in November 2024. The grievance, which was related to wound care procedures and other care concerns, was sent to the former administrator. Although the responsible party was informed that the administration was investigating the concerns, there was no documented follow-up or resolution provided to the responsible party. Review of facility grievance records from January 2024 onward did not show any documentation of the November 2024 grievance, and staff interviews revealed uncertainty about whether an official grievance was completed or properly tracked. The resident involved was assessed as being severely impaired in making daily decisions and was dependent on staff for activities of daily living, with a family member designated as the responsible party and health care representative. Interviews with current and former administrative staff indicated a lack of clear documentation and follow-up regarding the grievance, and the facility's grievance log did not reflect the reported concern. The facility's policy required the administrator to oversee and track grievances through to their conclusion, but this process was not followed in this instance.