Failure to Investigate Resident Grievance Regarding Drinking Water Source
Penalty
Summary
The facility failed to thoroughly investigate and address a grievance raised by a resident and their family regarding the source of drinking water provided to the resident. The resident, who was cognitively intact and diagnosed with parkinsonism, expressed being upset when a staff member obtained drinking water from a shared bathroom sink. The resident reported this concern to staff and informed their power of attorney. Despite these reports, a review of the resident's clinical record and the facility's grievance logs showed no documentation of the complaint or any related family concerns. Interviews with nurse aides confirmed awareness of the family's preference against using bathroom water and indicated that the concern had been reported to nursing staff and management. However, staff reported that they had not received clear guidance on where to obtain water for the resident. The DON acknowledged that the concern was reported by the resident's spouse but did not consider it a grievance, citing the family's history of multiple complaints and deeming this issue a non-issue. As a result, the facility did not initiate a formal grievance investigation or resolution process as required by policy.