Failure to Promptly Resolve and Document Resident Grievances
Penalty
Summary
The facility failed to ensure prompt efforts to resolve grievances voiced by a resident's family, as required by both regulation and facility policy. The family filed grievances on two separate occasions regarding the resident's care, specifically about the placement and accessibility of the call light and the conduct of night staff. Documentation revealed that the grievance forms were incomplete, lacking information on the resolution, notification to the family, and signatures. The facility's grievance policy required written responses and notification of findings, but these steps were not followed. The resident involved was an elderly female with multiple complex medical conditions, including recurring urinary tract infections, renal failure, diabetes mellitus, and was on hospice care. She was cognitively moderately impaired and dependent on staff for most activities of daily living, including mobility, hygiene, and toileting. The family reported that the resident was unable to operate the call bell unless it was placed on her chest, and staff were inconsistent in ensuring the call light was within reach. Despite interventions discussed with the clinical team, such as implementing a sign-in log for staff to document call light placement, the log was not consistently posted or used, and staff had not been trained on its use. Interviews with staff and family confirmed that the sign-in log was missing for a period, and staff were not consistently checking or documenting call light placement as required. The family also reported that staff did not check on the resident throughout the night, and that their concerns about staff empathy and visitation were not adequately addressed or documented. The facility's failure to document grievance resolutions and notify the family as per policy contributed to the deficiency.