Failure to Initiate, Investigate, and Resolve Resident Grievances
Penalty
Summary
The facility failed to initiate, investigate, and resolve grievances for six of twelve sampled residents, as required by its grievance policy. The Administrator, who is designated as the Grievance Official, did not maintain an up-to-date grievance log, and several grievances submitted by residents were not entered into the log or followed up with complete documentation of resolution, actions, recommendations, or notification to the residents. For example, one resident reported a malfunctioning mechanical lift that caused pain and submitted two grievances, but did not receive a timely response, and the grievance was not logged or resolved. Another resident filed a grievance about staff behavior that triggered their anxiety, but there was no entry in the log or evidence of resolution or notification. Additional residents reported grievances related to inadequate hygiene assistance and other concerns, which were similarly not documented or resolved according to policy. Interviews with staff confirmed that the grievance log was not current and that grievances were not being tracked or managed as required. The Maintenance Director also stated there was no log for mechanical lift inspections. Review of the grievance forms for the affected residents showed incomplete documentation and lack of follow-up. The facility's failure to follow its own grievance procedures resulted in unresolved grievances and lack of communication with residents regarding the status or outcome of their complaints.