Failure to Initiate and Resolve Resident Grievance Regarding Missing Personal Items
Penalty
Summary
The facility failed to initiate, investigate, and resolve a grievance for a resident who reported a missing personal item. The resident, who had clear speech and was able to make themselves understood despite moderate memory impairment, reported to staff that their personal gallon bottle of hand soap was taken and replaced with wipes. The resident expressed dissatisfaction with using wipes for hygiene and stated that no staff offered to help them fill out a grievance form. Multiple interviews and observations confirmed that the resident repeatedly voiced concerns about the missing soap and later a missing washcloth, but no grievance form was initiated, and the issue was not documented in the facility's grievance log. Staff interviews revealed inconsistent understanding and application of the facility's grievance policy. While the Social Services Director and Resident Care Manager stated that staff should complete a grievance form when a resident raises a concern, the LPN involved considered the issue a safety matter rather than a grievance and did not process it accordingly. The administrator confirmed that grievances should be resolved within five days and documented, but no such documentation or resolution occurred for the resident's missing items.