Failure to Maintain Effective Grievance System and Documentation
Penalty
Summary
The facility failed to maintain an effective grievance system as required, as evidenced by missing and incomplete grievance documentation over a six-month period. Specifically, grievance forms were unavailable for four out of six months reviewed, and the forms that were available for one month lacked essential information such as actions taken to investigate grievances, summaries of conclusions, dates of resolution, corrective actions implemented, and documentation of how the disposition was communicated to the complainant. This deficiency was identified during a complaint survey following allegations from two residents, one regarding missing personal belongings and another concerning unreturned calls after voicing concerns. Interviews with the DON and Administrator confirmed that the facility's process involves documenting concerns on forms and distributing them to the appropriate departments, with an expectation that grievances are resolved within seven days and all details are documented. However, both the DON and Administrator acknowledged that the grievance forms for the reviewed period were either missing or not fully documented, and the facility was unable to provide forms for four of the six months requested. This lack of documentation and incomplete records demonstrated the facility's failure to establish and maintain an effective grievance policy and process.