Failure to Resolve and Document Resident Grievances
Penalty
Summary
The facility failed to ensure that resident grievances were resolved and that written decisions were issued, as required by policy. One resident, who was cognitively intact and had multiple medical diagnoses including GAD, bipolar disorder, DM2, HTN, CHF, and lupus, filed grievances regarding maintenance issues with her television and concerns about activities being conducted primarily in Spanish. Documentation revealed that the grievances were not fully addressed, with key sections of the grievance forms left blank, including the summary of findings, recommendations, actions taken, and the method of notifying the resident of the resolution. Record review of the facility's grievance binder showed a pattern of incomplete documentation, with several grievances in July, August, and September lacking evidence of resolution. Interviews with staff, including the Activities Director, Maintenance Assistant, Maintenance Director, and Administrator, confirmed that the grievances were not fully investigated or resolved. Staff acknowledged communication barriers and delays in addressing the resident's concerns, such as the lack of compatible TV remotes and the absence of cable service in the resident's room. The Administrator was aware of the unresolved issues but had not provided documentation of corrective actions or written decisions to the resident. The facility's grievance policy requires prompt efforts to resolve grievances and mandates that written decisions be issued to residents, including details such as the date received, summary of the grievance, investigative steps, findings, confirmation status, corrective actions, and the date of the written decision. Despite this, the facility did not follow its own procedures, resulting in unresolved grievances and a lack of communication with the resident regarding the outcomes of her complaints.