Failure to Implement Grievance Resolution Regarding Staff Assignment
Penalty
Summary
A resident filed a grievance regarding the conduct of a Certified Nursing Assistant (CNA), specifically concerning how the CNA spoke to the resident during care. The facility investigated the grievance and documented that the CNA would no longer be assigned to care for this resident, and this information was reportedly communicated to the scheduler. However, a review of the resident's electronic health record showed that the CNA continued to provide incontinence care to the resident on multiple occasions after the grievance was filed and the resolution was documented. Interviews with facility staff revealed that the scheduler was not informed of any restrictions regarding staff assignments for this resident, and the CNA confirmed that they continued to care for the resident, sometimes with another CNA present. The Nursing Home Administrator acknowledged an oversight in the grievance resolution process, specifically in communicating the outcome to the scheduler, which resulted in the failure to implement the agreed-upon resolution to the resident's grievance.