Failure to Provide Required Written Grievance Decisions and Investigations
Penalty
Summary
The facility failed to ensure that all written grievance decisions included the required elements such as steps taken to investigate the grievance, a summary of pertinent findings or conclusions, a statement as to whether the grievance was confirmed or not, any corrective action taken, and the date the written decision was issued. This deficiency was identified for two residents who had submitted grievances regarding their care and services. In both cases, the facility did not conduct thorough investigations, did not document corrective actions, and did not provide written decisions to the residents or their representatives. One resident, who had multiple complex medical diagnoses including hypertension, heart failure, and chronic pain, had a grievance submitted by her daughter regarding inadequate catheter care and lack of bathing. The grievance was acknowledged by the administrator through a phone call, but there was no documentation of an investigation, staff interviews, or corrective actions taken. The only notification provided was verbal, and no written resolution was issued as required by facility policy. Another resident, with diagnoses including heart disease, atrial fibrillation, anemia, hypothyroidism, depression, and dementia, had multiple grievances submitted by herself and her daughter. These grievances included concerns about delayed care, lack of regular care conferences, and an incident resulting in a femur fracture. The facility's documentation did not show that thorough investigations were conducted or that written notifications of resolutions were provided. Interviews with staff revealed confusion and lack of clarity regarding responsibility for the grievance process, and the required follow-up actions and documentation were not completed.