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F0585
D

Failure to Follow Grievance Policy and Communicate Resolutions to Family

Commerce, Michigan Survey Completed on 09-10-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to follow its own grievance policy regarding the follow-up of concerns raised by a resident's family member. The policy required that all concerns be entered electronically, investigated by the department leader, and that the person reporting the concern be informed of the resolution. In the case reviewed, a family member reported multiple concerns to the social worker and administration, including issues with a delay in treating an eye infection and the resident being left in a dirty nightgown. Although the facility documented the concerns and noted resolutions in their records, there was no evidence that staff followed up with the family member to communicate the outcomes or resolutions of these concerns. The resident involved had significant medical needs, including acute and chronic respiratory failure, hemiplegia and hemiparesis following a cerebral infarction, dysphagia, and required staff assistance for all activities of daily living. Despite the facility's policy and the family member's repeated attempts to communicate concerns, the administration and social services staff acknowledged that they only followed up with the resident, who was her own responsible party, and did not contact the family member who had reported the issues. No further explanation or documentation of follow-up with the family member was provided by the facility.

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