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F0585
D

Failure to Investigate and Resolve Resident Grievance Regarding Staff Cell Phone Use

Madison, Wisconsin Survey Completed on 05-05-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to document a thorough investigation and did not resolve a grievance as required by its own policy for one of four residents reviewed for grievances. A resident expressed concern during a Resident Council meeting about staff using personal cell phones while working. The concern was not entered into the facility's grievance log, and there was no documentation of an investigation or resolution. The Activities Director recalled the concern being brought to the previous Director of Nursing but was unsure if any follow-up occurred. The resident confirmed that no one had followed up with her regarding her concern, which remained unresolved at the time of the survey. Surveyors directly observed multiple staff members, including LPNs, using personal cell phones during work hours for non-work-related activities, such as opening a bank account, making a Facetime call, and discussing a resident. The Director of Nursing stated that there was no specific grievance documented regarding cell phones, although staff had reviewed cell phone expectations previously. The facility's policy requires the Grievance Official to oversee the grievance process, including receiving, tracking, investigating, and resolving grievances, as well as notifying the complainant of the outcome. These steps were not followed in this case.

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