Failure to Initiate, Investigate, and Resolve Resident Grievances
Penalty
Summary
The facility failed to properly initiate, investigate, and resolve grievances for three residents, as required by its grievance policy. For one resident with memory impairment and dependence on staff for daily living activities, the family repeatedly reported missing clothing to staff over several days. Despite these reports, no concern or comment form was completed, and the missing items were not found or replaced in a timely manner. Staff interviews confirmed that the appropriate grievance process was not followed, and the Director of Nursing acknowledged that a concern form should have been completed but was not. Another resident, who had no cognitive impairment and was able to communicate clearly, lost their dentures in the facility. The resident reported the loss to staff, and a staff member stated they completed a concern and comment form, but there was no documentation of the grievance in the facility's log or the resident's record. The administrator confirmed that the grievance was not logged as required, and staff did not follow up with the grievance process. A third resident, who used glasses and experienced frequent pain, submitted a grievance alleging that a nurse had swapped their pain medication for a different pill. The concern and comment form was incomplete, lacking staff signatures and dates, and the summary response did not indicate whether the resident was satisfied with the outcome or who authored the summary. Staff interviews confirmed that the grievance documentation was incomplete and did not meet policy requirements.