Failure to Document and Address Resident Grievances
Penalty
Summary
The facility failed to ensure that residents' verbal concerns were documented and processed as grievances according to its own policy. For two residents, both of whom were cognitively intact based on their BIMS scores, verbal complaints regarding the care provided by a specific CNA were reported to nursing staff but were not entered into the grievance system. One resident reported an incident where a CNA spilled urine on him, reused a soiled brief, and did not return to complete care. This concern was communicated to an RN, who acknowledged that a grievance form should have been completed but did not do so. The facility's grievance log showed no record of this complaint. Another resident expressed dissatisfaction with the same CNA, stating that her care was rough and that she did not adequately clean him, leaving him soiled. He also reported that other residents shared similar concerns and requested not to have this CNA provide their care. This resident communicated his concerns to an LPN, but again, no grievance form was completed and no entry was made in the grievance log. The facility administrator confirmed that verbal concerns about care and services should be documented on a grievance form and followed up by the Grievance Officer, which did not occur in these cases.