Failure to Timely Resolve and Document Resident Grievances
Penalty
Summary
The facility failed to resolve grievances in a timely manner for two residents who voiced concerns about their care and communication. One resident, a female with paraplegia, diabetes, and a urinary catheter, reported ongoing issues with staff not using proper personal protective equipment (PPE) during catheter care, improper cleaning of her catheter, and staff refusing to assist her when she experienced pain and issues with her catheter. She stated that she reported these concerns to the Director of Nursing (DON), who documented the issue on a sticky note but did not follow up or provide her with a copy of her grievance. The resident was unable to write due to hand contractures and required staff assistance to document her concerns, which was not consistently provided. Interviews with CNAs confirmed ongoing concerns about infection control and lack of response from the Registered Nurse Unit Manager (RNUM), but no additional grievance forms were found to address these issues. Another resident, a male with a history of stroke and spinal cord disease, expressed frustration with the lack of communication regarding his outside medical appointments. He reported that he was not informed of appointments in advance and was unaware of the facility's grievance process. The resident stated that staff did not offer to help him complete a concern form, despite his difficulty writing. During an interview, the facility's Social Worker acknowledged the concern but did not offer to complete a grievance form, instead stating she would relay the issue to the scheduler. The Appointment Scheduler confirmed attempts to arrange the resident's orthopedic appointment but was unaware of the resident's desire for earlier notification. The Nursing Home Administrator was not aware of the resident's concerns until informed during the survey and noted that staff education on the grievance process was ongoing. The facility's policy required that grievances be documented and responded to promptly, with actions taken to prevent potential violations of residents' rights. However, the investigation found that grievances were not consistently documented, residents were not always assisted in filing grievances when unable to do so themselves, and timely follow-up and resolution were lacking. The absence of proper documentation and response to residents' concerns, particularly regarding infection control and communication about medical appointments, constituted a failure to honor residents' rights to voice grievances without discrimination or reprisal.