Failure to Promptly Resolve and Document Resident Grievances
Penalty
Summary
The facility failed to ensure prompt resolution of grievances for two residents, as required by its own grievance policy and federal regulations. In the first instance, a resident's representative voiced concerns regarding the resident being rushed during meals and not being allowed to finish eating, as well as improper positioning on a shower chair. These concerns were communicated to facility staff but were not entered into the facility's grievance log, nor was there evidence of follow-up or investigation according to the facility's grievance process. Interviews with staff, including the Nursing Home Administrator (NHA) and Director of Nursing (DON), confirmed that these concerns were not documented or tracked as grievances. In the second instance, another resident's representatives raised concerns during a meeting, which were documented in the resident's medical record and hospice notes. The concerns included late meal service, the need for assistance with menus, and the use of a different lift. Despite being documented, these concerns were not entered into the facility's grievance log, and there was no evidence that the facility's grievance process was followed. Multiple staff members, including hospice staff and registered nurses, indicated unfamiliarity with the grievance process or stated that they had never filled out a grievance form, further contributing to the lack of proper documentation and follow-up. The facility's policy requires that all grievances, whether verbal or written, be promptly recorded, investigated, and tracked through to resolution, with documentation retained for at least 18 months. However, interviews and record reviews revealed that staff were unclear about their responsibilities in reporting and documenting grievances, and that concerns voiced by residents or their representatives were not consistently handled according to policy. This resulted in grievances not being tracked, trended, or resolved in a timely manner, as required.