Failure to Initiate Grievance for Resident's Transportation Complaint
Penalty
Summary
The facility failed to timely initiate a grievance for a resident who voiced complaints regarding transportation arrangements to a dialysis appointment. The resident, who had kidney failure and was dependent on renal dialysis, was transported by foot in a wheelchair by facility staff for approximately 30 minutes to the dialysis center, as no vehicle transport was provided. During this trip, the resident complained of being cold and expressed dissatisfaction with the mode of transportation to both dialysis and facility staff. Despite these complaints, no grievance form was completed, and the incident was not logged in the facility's grievance record for the month. Interviews with facility staff confirmed awareness of the resident's complaints and frustration, including the resident's desire to be discharged from the facility. Staff reported that the resident was dressed in warm clothing and had a blanket, but still complained of being cold during the trip. The facility's grievance policy required prompt resolution and recordkeeping of all grievances, overseen by the executive director or designee. However, the resident's complaints were not documented or addressed through the formal grievance process, as required by policy.