Failure to Investigate and Resolve Resident Grievances per Facility Policy
Penalty
Summary
The facility failed to honor residents' rights to voice grievances without discrimination or reprisal, and did not follow its own grievance policy for two residents. The policy requires prompt investigation, documentation, and resolution of grievances, overseen by a designated Grievance Official. In both cases, the facility did not document a thorough investigation or resolve the grievances as outlined in their procedures. One resident, who had moderate cognitive impairment and multiple mobility-related diagnoses, expressed concerns about not receiving assistance when moving from the dining room to his room. Progress notes indicated that the resident was upset about not being helped and voiced his intention to report the issue. Staff interviews revealed that the concern was not reported as a grievance, and the required documentation and investigation were not completed. The staff acknowledged that the resident frequently expressed such concerns, but no formal grievance process was initiated in response to his repeated complaints. Another resident with a history of diabetic foot ulcers voiced a grievance about wound care, specifically not wanting a particular nurse practitioner to debride her wound due to increased pain. The resident reported her concerns to both the Nursing Home Administrator and a nurse. Although an administrative assistant recognized the concern as a grievance and reported it to the administrator, no grievance form was completed and the facility did not follow up according to its policy. In both cases, the facility did not adhere to its established grievance procedures, failing to ensure prompt investigation, documentation, and communication with the residents involved.