Failure to Provide Written Grievance Response Summaries
Penalty
Summary
The facility failed to provide written grievance response summaries to residents' representatives (RRs) for grievances filed on behalf of three residents. According to the facility's grievance policy, the Grievance Official is required to inform the resident of the results of the investigation and provide a written grievance decision upon request. However, the policy did not specify procedures for handling grievances filed by individuals other than the resident, such as RRs. Review of the grievance logs and concern forms revealed that, in each case, the resolution of the grievance was communicated verbally, either by phone or in person, but no written summary was provided to the RRs. For one resident, who was cognitively intact, the RR filed a grievance regarding negative staff interaction. The concern form indicated that the Social Worker notified the RR by phone, but no written response was given. The RR confirmed during an interview that she had never received or been offered a written resolution, only verbal communication. Similar patterns were observed for two other residents: one with moderately impaired cognition and another who was cognitively intact. Their RRs initiated multiple grievances related to staff concerns, laundry, care, and cleanliness, but in each instance, the resolution was communicated verbally, and no written summary was provided. Interviews with the Social Worker, who maintained the grievance log, revealed a lack of awareness that a written response was required for grievances. The Administrator acknowledged awareness of the requirement for written grievance responses but was not aware that this was not being consistently offered or provided to RRs. The deficiency was identified through record review, interviews with RRs, and staff interviews, all confirming the absence of written grievance response summaries as required by regulatory guidelines.