Failure to Investigate and Resolve Resident Grievances
Penalty
Summary
The facility failed to uphold and operationalize its grievance policy, resulting in multiple grievances from residents and their representatives not being investigated or resolved. Documentation was incomplete or missing for grievances, with no evidence of follow-up, investigation, or communication of outcomes to the complainants. Staff interviews revealed that grievances were often deprioritized, and some staff only investigated complaints if they suspected abuse, otherwise taking no further action. Grievances submitted through resident council meetings and grievance boxes were not consistently included in the official grievance binder, and many lacked required documentation such as investigation steps, findings, or resolution status. Several residents reported ongoing care concerns, including not being repositioned as required for pressure ulcer prevention, delayed response to call lights, and improper medication administration. Residents and staff described repeated complaints about care issues such as lack of showers, long call light response times, and being left wet overnight, with no evidence that these concerns were addressed. Some grievances involved allegations of staff causing injury during care, but these were not investigated as potential abuse or neglect, nor were they reported as required by facility policy. Facility records and interviews indicated a systemic breakdown in the grievance process, with staff acknowledging that grievances were not prioritized and often ignored. The facility's own policy required acknowledgment, investigation, and documentation of all grievances, including reporting of alleged abuse or neglect, but these steps were not followed. As a result, residents and their representatives did not receive responses or resolutions to their concerns, and there was no documentation of corrective actions or communication regarding the outcomes of their grievances.