Failure to Provide Written Grievance Responses
Penalty
Summary
The facility failed to provide written grievance decision responses to two residents who had filed grievances, as required by both facility policy and federal regulations. The policy in place specified that residents or their representatives must receive a written decision at the conclusion of a grievance investigation, including details such as the date received, investigative steps, findings, confirmation status, corrective actions, and the date the decision was issued. However, documentation for multiple grievances showed that only verbal notifications were given, and there was no evidence that written responses were provided. One resident, admitted with intact cognition, filed a grievance regarding another resident and was verbally informed of the resolution by the Social Services Director (SSD). The resident confirmed during an interview that they had not received a written response and were unaware that such documentation could be provided, expressing a desire to receive written outcomes for their grievances. Similarly, another resident with intact cognition filed several grievances, including dietary concerns and issues involving other residents. In each instance, the documentation indicated verbal notification only, with no written decision provided to the resident. Interviews with the SSD, DON, and Administrator revealed a lack of awareness regarding the requirement to provide written grievance responses. The SSD, who had been responsible for investigating and resolving grievances, stated she was not aware of the written response requirement and had only provided verbal updates. Both the DON and Administrator also indicated they were unaware of this requirement, though they expected the grievance official to follow facility policy.