Failure to Document and Address Resident Grievance Regarding Staff Conduct
Penalty
Summary
The facility failed to follow its grievance process by not documenting or initiating a grievance for a resident who reported feeling unsafe and uncomfortable due to alleged rough handling by CNA staff. The resident, who was cognitively intact and had multiple psychiatric and medical diagnoses, voiced her concerns to a registered nurse, but there was no documentation in the grievance log or in the resident's progress notes regarding the incident. Staff interviews revealed inconsistent understanding and application of the grievance process, with some staff indicating they only document grievances at their own discretion and others admitting to never having received grievance training. Training records confirmed that a significant portion of staff, including direct care staff, had not attended recent grievance training. Further interviews with facility leadership indicated a lack of clear parameters for what constitutes a grievance and inconsistent practices in documenting and addressing resident concerns. The facility's grievance policy requires that all complaints or grievances be documented and acted upon promptly, with follow-up and communication to the resident. However, in this case, the policy was not followed, and the resident's expressed concerns were not formally addressed or investigated as required.