Failure to Document and Resolve Resident Grievance
Penalty
Summary
The facility failed to document, follow up, and resolve a grievance for one resident who was moderately cognitively impaired and required maximum assistance for all activities of daily living. The resident's Power of Attorney (POA) reported an incident where the resident, while being transferred using a mechanical lift, was not positioned correctly, resulting in the resident screaming in pain and being forced to have a bowel movement in a garbage can. The POA communicated these concerns multiple times, including via email, and specifically requested that the involved CNAs not provide further care to the resident. Despite these requests, the same CNAs continued to care for the resident, and the POA was told by the Interim DON that no further action could be taken and that the CNAs were not the resident's primary caregivers. The facility did not maintain a grievance log or reports for the past three months, and the Interim DON did not report the POA's concerns to the designated Grievance Officer, believing the concerns did not warrant being classified as a grievance. The Administrator in Training was informed of the situation but was told by the Interim DON that it was being handled and did not need to be elevated to a grievance report. The Grievance Officer later confirmed that the concerns should have been reported as a grievance, as per facility policy, which allows grievances to be raised by residents, representatives, staff, or visitors and does not require a formal written complaint.