Failure to Resolve and Communicate Grievance Outcomes
Penalty
Summary
The facility failed to make prompt efforts to resolve grievances and did not keep a resident's responsible party (RP) appropriately informed of progress toward resolution. The resident in question was an elderly female with severe cognitive impairment, as indicated by a BIMS score of 2 out of 15, and multiple medical diagnoses including vascular dementia, hypertension, and irritable bowel syndrome. The resident's RP submitted three grievances related to medication administration, unexplained bruising, and the need for a podiatrist appointment. These grievances were submitted on the morning the resident passed away. Record review showed that the facility's Grievance/Concern Report had a blank section for resolution, and there was no documented response or communication of the investigation's findings to the resident's RP. Interviews with facility staff revealed that the DON began investigating the grievances but had to leave for surgery, at which point the investigation was not clearly handed off to the ADON. The ADON did not investigate the concerns or communicate with the RP, and the SW stated she attempted to contact the RP but did not document the attempt or recall if a message was left. As of the time of the survey, the RP had not received any update or resolution regarding the grievances filed. The facility's policy required prompt efforts to resolve grievances and to keep residents or their representatives informed, but this was not followed in this case. The lack of communication and documentation resulted in the RP not being apprised of the findings or resolution of the grievances, despite multiple staff being aware of the concerns and the facility's policy outlining their responsibilities.