Failure to Investigate and Document Resident Grievances Regarding Missing Personal Items
Penalty
Summary
The facility failed to thoroughly investigate and document grievances related to missing personal items for a resident. The resident, who was cognitively intact and had multiple medical diagnoses including morbid obesity, type II diabetes, anxiety disorder, and stage III chronic kidney disease, reported that several items of clothing had gone missing while residing in the locked unit. Despite providing detailed lists of missing items to Social Services, and the family also communicating concerns to the Administrator, the facility did not conduct a comprehensive investigation or follow up with the resident or her family to resolve the issue. The resident's concerns were not entered into the facility's grievance log, and there was no documented inventory of her personal items in the medical record. Interviews with staff revealed that Social Services received multiple lists of missing clothing from the resident over several days and attempted to locate some items in the resident's room and laundry, marking off what was found. However, Social Services did not follow up on the remaining missing items, assuming the issue was resolved when it was not mentioned again. The Administrator also acknowledged being informed of the missing items by the resident's family but did not pursue further investigation or communication after initially requesting a list of missing items from the family, which was not received. The Director of Nursing confirmed that the resident's concerns were not documented in the grievance log as required by facility policy. Facility policy required immediate action and a timely investigation upon receipt of any grievance, whether oral or written, to prevent further violations. Despite this, the facility did not document or investigate the resident's repeated reports of missing clothing, nor did it communicate outcomes or resolutions to the resident or her family. The lack of follow-up and documentation resulted in the resident and her family having to replace the missing items themselves, with the value of the lost clothing estimated at around $600.