Failure to Investigate and Resolve Resident Grievance
Penalty
Summary
The facility failed to thoroughly investigate and promptly resolve a grievance for one resident who was cognitively intact at the time of the incident. The resident reported that, in early September, staff left them soiled and dripping urine, and threatened not to answer their call light all night. The resident stated they informed social services staff, but felt ignored. Review of the facility's grievance log did not show any grievance filed for this incident. An undated grievance form indicated the resident had reported a delay in staff response to their call light, resulting in wet clothing and bedding, and expressed dissatisfaction with the staff's attitude. However, there was no documentation of follow-up or investigation regarding the grievance. Staff interviews revealed that the social services assistant was aware of the resident's complaint and had spoken to the staff member involved, but did not document any actions taken or follow-up. The administrator confirmed that the facility's process required grievances to be logged and investigated, regardless of whether the resident wanted to pursue the matter further. The administrator was not aware of the incident until the day of the survey and acknowledged that the grievance could be a potential allegation of abuse or neglect, which should have triggered an investigation according to facility policy.