Failure to Address and Document Resident and Staff Grievances Without Retaliation
Penalty
Summary
The facility failed to honor residents' and staff members' rights to voice grievances without discrimination or reprisal, as required by federal and state regulations. Review of facility documentation and interviews revealed that grievances and concerns submitted by both residents and staff were not properly documented, investigated, or followed up on. Specifically, two residents reported filing both verbal and written grievances regarding aggressive behavior by another resident, but no action was taken, and they did not receive written confirmation of any investigation or resolution. Additionally, these residents reported being threatened by staff to stop filing grievances and noted that grievance forms were sometimes unavailable, forcing them to submit concerns verbally and compromising their anonymity. Staff interviews further revealed that employees who attempted to file grievances were threatened with job loss if they continued, leading them to stop submitting grievances on behalf of residents out of fear of retaliation. The facility's grievance log for the past six months showed only a few grievances, with some being misclassified or not properly investigated. The Nursing Home Administrator and Director of Nursing confirmed that the facility failed to address concerns raised by staff and residents.