Failure to Provide Written Grievance Summaries to Residents
Penalty
Summary
The facility failed to provide written grievance summaries to residents or their representatives as required by its own grievance policy. For two residents who were both severely cognitively impaired, grievances were filed regarding concerns such as inadequate nail care, improper dressing for appointments, and lack of assistance with bathroom transfers. In both cases, the grievance logs and forms either lacked documentation of written notification of the resolution or contained written summaries that did not correspond to the specific concerns raised. Staff interviews revealed that key personnel, including the Administrator, Director of Nursing, and Social Worker, were unaware of the requirement to provide written grievance summaries to residents or their representatives. Instead, resolutions were communicated verbally or not at all, and written documentation was either missing or incomplete. This resulted in the facility not adhering to its policy and regulatory requirements for grievance resolution documentation.