Failure to File and Investigate Grievance for Missing Resident Items
Penalty
Summary
The facility failed to ensure that a grievance was filed, investigated, and resolved for a resident who reported missing personal items. The resident, who was admitted with diagnoses including muscle wasting, atrophy, MRSA infection, and osteomyelitis, reported missing a blanket and several blouses. The resident and a family member searched the laundry room for the missing items, but not all items were recovered. Despite the resident's repeated complaints and the involvement of multiple staff members, including the Admissions Director and Housekeeping Director, no formal grievance was filed regarding the missing items. Interviews with staff revealed a lack of clarity and communication regarding the grievance process. The Social Services Director was unaware of the missing items and confirmed that no grievance had been logged. The Admissions Director and Housekeeping Director both acknowledged the resident's complaints but did not initiate the grievance process, assuming the issue was being addressed informally. The facility's policy requires staff to assist residents in filing grievances and to document and investigate concerns, but this procedure was not followed in this case.