Failure to Document and Address Resident Grievance Following Verbal Altercation
Penalty
Summary
The facility failed to ensure that residents could voice grievances without discrimination or reprisal, as required by policy. On the morning of 8/14/2025, a resident with a history of mood disorder and schizoaffective disorder became involved in a verbal altercation with another resident who had dementia and impulse disorders. The incident began when the first resident refused to share his personal coffee creamer with the second resident, leading to a shouting match with exchanged insults. The situation escalated to the point that other residents in the dining room were emotionally disturbed. Following the altercation, the first resident was visibly upset and reported his complaint about the other resident's behavior to LVN A, expressing that he felt his grievance was not being taken seriously. Despite the resident's clear attempt to voice a grievance, LVN A did not generate a grievance report as required by facility policy, although she did document the incident in the nursing progress notes and reported it to the RN supervisor. The facility's grievance log for the month was found to be blank, indicating that no grievances were documented, including this incident. Interviews with staff and review of facility policy confirmed that all grievances, whether oral or written, should be documented and reported to leadership for investigation and resolution. The DON was unaware of the grievance and stated that both LVN A and the RN supervisor were responsible for ensuring grievances were documented and reported to the grievance coordinator. The failure to document and address the resident's grievance represented a violation of the residents' rights and facility policy.