Failure to Promptly Address and Document Grievances Related to Resident Care
Penalty
Summary
The facility failed to make prompt efforts to resolve grievances regarding a resident's care and treatment, as required by regulation. The responsible party (RP) for a resident voiced multiple concerns to various management staff about poor nursing care, issues with the resident's PICC line, wound vac, antibiotic medication, and falls. Despite these concerns being communicated, the facility did not document the grievance, nor did they respond or follow through according to their grievance policy. Interviews with facility staff confirmed that no grievance was entered into the system for these concerns, and the responsible party was not provided with written grievance decisions as outlined in the facility's policy. The resident involved had significant medical needs, including a history of sepsis, a closed fracture of the right femur, dementia with behavioral disturbance, Alzheimer's disease, and a recent major surgery. She required extensive wound care, IV therapy, and was administered high-risk medications such as anticoagulants and antibiotics. The resident was dependent on staff for activities of daily living and was at risk for pressure ulcers and falls. The responsible party reported not being notified about critical changes in the resident's care, such as the inability to flush the PICC line, the switch from IV to oral antibiotics, and the dislodgement of a urinary catheter. These concerns were not formally documented as grievances, and the responsible party was not kept informed as expected. Facility interviews revealed a lack of clarity and consistency in the grievance process. While some staff believed that communication and documentation in the resident's chart were sufficient, others acknowledged that the concerns raised should have been treated as formal grievances. The facility's policy required that all grievances be documented, investigated, and responded to in writing, but this process was not followed for the concerns raised by the responsible party. The failure to document and address these grievances meant that the resident's care concerns, including missed medications and issues with wound and IV care, were not properly investigated or resolved.