Failure to Document and Address Resident Grievances
Penalty
Summary
The facility failed to ensure that residents' grievances were properly documented, reported, and addressed according to its grievance policy. In two separate cases, residents voiced concerns to staff members regarding their care and services, but these grievances were neither documented nor reported to facility leadership as required. One resident, who had a history of blindness, diabetes, and chronic kidney disease, alleged that he did not receive his medications over a weekend. Although he communicated this concern to a medication aide, the aide did not document the grievance or report it to the Director of Nursing (DON). The medication aide stated she verbally informed a weekday nurse, but the nurse did not recall receiving such a report and confirmed that she would have documented and escalated the issue if she had been informed. In another instance, a resident with atherosclerotic heart disease, dementia, and mobility difficulties was left at a doctor's office for several hours without transportation back to the facility. The resident and his representative reported this grievance to a case manager, who did not document the complaint or report it to the DON. The case manager recalled discussing the incident with the resident's representative but did not complete a grievance report. Facility leadership, including the Administrator and DON, confirmed they had not received reports of either grievance and emphasized that all grievances should be documented and reviewed according to policy. A review of the facility's grievance policy indicated that residents have the right to voice concerns regarding care, treatment, staff behavior, and other issues without fear of reprisal, and that the facility is responsible for making prompt efforts to resolve such grievances. However, the lack of documentation and reporting in these cases resulted in the grievances not being recognized or addressed by facility leadership, contrary to the established policy.