Failure to Initiate and Resolve Resident Grievance Regarding Roommate Encroachment
Penalty
Summary
The facility failed to initiate, investigate, and resolve a grievance for a resident who reported ongoing issues with their roommate encroaching on their personal space and cluttering shared areas. The resident, who had neurological conditions, memory impairment, and required assistance with personal hygiene, stated that their access to the closet, sink, and bathroom was obstructed by their roommate's belongings. Despite informing nursing staff on several occasions, the resident received no follow-up or resolution, and no grievance report was completed as required by facility policy. Observations confirmed the clutter and obstruction in the room, and interviews with staff revealed a lack of awareness or action regarding the resident's complaints. Staff members, including a CNA, social services, nurse supervisor, and DON, acknowledged either being unaware of the specific grievance or failing to complete the necessary grievance documentation. The facility's policy required staff to complete a grievance form for any resident concern or complaint, forward it to appropriate departments, and provide feedback to the resident. However, in this case, the process was not followed, and the resident's concerns were not formally addressed or tracked, resulting in unresolved issues and lack of communication with the resident.