Failure to Forward and Address Resident Grievance Regarding Lost Personal Item
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident's grievance regarding a lost cell phone was properly forwarded to the grievance official and addressed according to policy. The resident, who was cognitively intact and had diagnoses including hypertension and flaccid hemiplegia, reported to nursing staff that her cell phone had been missing for a couple of months. Despite informing staff, the resident did not receive any follow-up regarding the lost item and had to use the nurse's station phone to make or receive calls. The resident's care plan indicated that she enjoyed talking with her family on the phone, highlighting the importance of the missing item to her daily life. Interviews with staff revealed that a CNA was aware of the missing phone and verbally informed the Social Service Director (SSD), but no grievance form was completed or forwarded as required by facility policy. The SSD could not recall being told about the missing phone and confirmed that no grievance form was filled out. The facility's grievance policy specified that staff receiving a grievance must document it on a designated form and forward it to the grievance official, who is responsible for tracking and resolving grievances. This process was not followed in the case of the resident's lost cell phone.