Failure to Follow Grievance Policy and Ensure Resident Follow-Up
Penalty
Summary
The facility failed to follow its established grievance policies and procedures for investigating and following up on resident grievances for five out of six sampled residents. Multiple residents reported that after filing grievances, the facility did not provide follow-up or resolution. One resident stated that grievances regarding being awoken by a CNA and missing items were never addressed, while two other residents reported that their joint grievance about staff not distributing water and using personal phones during care remained unresolved, with no staff discussing the issues with them. Another resident indicated that grievances from a previous month had not been resolved or followed up on, and a fifth resident confirmed that his grievance had not been addressed or followed up by staff. Interviews with staff revealed a lack of clarity and consistency in the grievance follow-up process. The social services staff member interviewed stated that follow-up depended on the specific situation and confirmed that there was no designated person responsible for ensuring residents were informed about the status or resolution of their grievances. This lack of a clear process resulted in residents not being updated or assured that their concerns were being addressed. A review of the facility's grievance policy showed that it requires prompt efforts to resolve concerns, documentation of resident satisfaction upon completion of investigations, and clear assignment of responsibility for follow-up. Despite these requirements, the facility did not ensure that grievances were investigated, resolved, or communicated back to the residents, as evidenced by the residents' statements and staff interviews.