Failure to Follow Grievance Process and Incomplete Documentation
Penalty
Summary
The facility failed to follow its established grievance process for two residents who voiced concerns regarding their care. One resident, with diagnoses including cerebral palsy, major depressive disorder, unspecified psychosis, and schizoaffective disorder, was cognitively intact and dependent on staff for hygiene. This resident filed a grievance about prolonged wait times to get out of bed and staff turning off the call light. Although the Social Services Director (SSD) acknowledged the complaint and stated that staff had been educated, the grievance form was incomplete, unsigned, and did not document resolution, contrary to facility policy requiring prompt resolution and proper documentation. Another resident, also cognitively intact and with multiple medical conditions, reported being denied a shower on a non-scheduled night and subsequently being left soiled until the following morning. The grievance was not entered into the facility's grievance log, and the documentation was incomplete, lacking signatures, dates, and statements from all involved staff. The Social Service Assistant (SSA) and SSD confirmed the grievance was not logged, and the Director of Nursing (DON) admitted to incomplete staff interviews and missing documentation. The Nursing Home Administrator (NHA) acknowledged that the grievance was not properly reviewed or discussed by the management team. Facility policy requires that all grievances be logged, investigated, and resolved promptly, with residents kept informed of progress and provided with a written decision. In both cases, the facility did not adhere to its own grievance procedures, resulting in incomplete documentation, lack of timely resolution, and failure to keep residents appropriately apprised of the status of their grievances.