Failure to Initiate and Document Grievance Process for Lost Hearing Aids
Penalty
Summary
The facility failed to ensure that a resident's right to voice grievances was honored and that prompt efforts were made to resolve those grievances. Specifically, a resident with a history of diabetes, chronic kidney disease, uterine cancer, major depressive disorder, hypertension, and heart failure reported the loss of her hearing aids, which were routinely collected by nursing staff for charging. The resident communicated the loss to the social worker (SW), who acknowledged being told about the missing hearing aids but did not initiate the facility's grievance process as required by policy. The SW attempted to find a replacement provider but did not document or formally report the grievance. Additionally, a Licensed Vocational Nurse (LVN) was made aware of the missing hearing aids but did not initiate the grievance process or report the issue to her supervisor until prompted by the surveyor. The LVN supervisor and assistant administrator both confirmed that they were not informed of the missing hearing aids until much later, and the facility's grievance log showed no record of a grievance being filed for this incident. Interviews revealed that staff were unclear about the proper procedures for reporting and documenting grievances, despite the facility's policy requiring any employee to report grievances to their department head or charge nurse and for a written report to be initiated. The facility's grievance policy states that residents or their representatives have the right to file grievances orally or in writing and expect a written decision within seven working days. However, in this case, the process was not followed, and the resident's concern about her missing hearing aids was not formally addressed through the established grievance system. This failure was identified through interviews and record reviews, which showed a lack of documentation and appropriate response to the resident's complaint.