Failure to Promptly Resolve and Document Resident Grievance
Penalty
Summary
The facility failed to ensure prompt and effective resolution of a grievance filed by a resident's representative regarding the resident's physical therapy and weight-bearing status. The representative expressed concerns that the weight-bearing orders from the orthopedic surgeon were not being followed and reported dissatisfaction with the explanations provided by the director of rehabilitation. Despite attempts to communicate these concerns, including an email to the nursing home administrator, the representative did not receive a satisfactory response or resolution. A review of the grievance documentation revealed that the grievance form was incomplete, lacking required signatures, substantiation status, and a clear indication of resolution or satisfaction. The form noted the representative's continued concerns and hesitancy regarding the outcome. Staff interviews confirmed that the facility's grievance process was not properly followed, as there was no documentation of when the grievance was resolved or whether the resolution met the representative's satisfaction. The facility's policy required thorough documentation and timely resolution, which was not demonstrated in this case.