Failure to Maintain Effective Grievance System and Staff Training
Penalty
Summary
The facility failed to maintain an effective system for receiving, tracking, and resolving resident and/or representative grievances, as required by its own grievance policy. Review of the facility's grievance binder revealed missing records for several months and incomplete documentation for others. During a Resident Council meeting, residents expressed confusion about how to file grievances and reported a lack of follow-up on submitted concerns. Staff interviews confirmed a lack of training and understanding regarding the grievance process, with some staff unaware of the location or purpose of grievance forms and others believing it was not their responsibility to assist residents with grievances. The Social Services staff acknowledged the absence of a consistent protocol for processing grievances and a tracking system to monitor resolution. One resident, admitted with diffuse large B-cell lymphoma and type 2 diabetes, experienced a significant delay in transportation after a medical appointment. The resident attempted to file a grievance regarding the 20-hour wait but did not receive the necessary form or follow-up from staff. The nurse involved admitted to not providing the grievance form and was unaware of its location. Other staff members also demonstrated confusion about the grievance process and the availability of forms, with some believing the forms were intended for employees rather than residents. The facility administrator confirmed that there was no clear system in place for tracking grievances or ensuring that concerns were addressed and resolved. The lack of a functioning grievance procedure and inadequate staff training placed residents at risk for unreported and unresolved grievances, as evidenced by incomplete records, staff confusion, and resident reports of unresolved issues.