Failure to Document and Investigate Resident Grievance Regarding Discarded Food
Penalty
Summary
The facility failed to ensure that all written grievance decisions included required documentation such as the date the grievance was received, a summary of the grievance, steps taken to investigate, findings or conclusions, confirmation status, corrective actions, and the date the decision was issued. Specifically, a resident with diagnoses including cerebrovascular disease, dysphagia, aphasia, depression, and generalized anxiety disorder, who was cognitively intact, verbally complained about his food being discarded after storing it in a refrigerator near the nurses' station. The resident reported labeling his food with his name and date, but discovered it was missing when he attempted to retrieve it. Interviews with facility staff, including the social worker, LVN, DON, and administrator, confirmed that the resident had a history of storing his own food and had previously raised concerns about food being discarded. The LVN recalled the resident being upset about his food being thrown away and stated she verbally reported the grievance to the ADON (now DON). However, there was no documentation of this grievance in the facility's grievance log, and no grievance form was completed for the incident. The facility's grievance policy requires that all concerns be documented and investigated, with a written decision provided. Despite this, the process was not followed in this case, as the resident's complaint was not formally documented or investigated according to policy. The lack of documentation and follow-through could prevent residents' concerns from being properly addressed and resolved.