Failure to Promptly Address and Resolve Resident Grievance Regarding Personal Care
Penalty
Summary
The facility failed to ensure that a resident's grievance regarding personal care was addressed in a timely and effective manner, as required by its own grievance policy. The resident, who had severe cognitive impairment, was dependent on staff for all activities of daily living and required specialized equipment for mobility and transfers. Her representative repeatedly requested that the resident receive regular haircuts, as had been her routine, but these requests were not acted upon for several months after the facility's beautician position became vacant. Documentation shows that the resident's representative brought up the need for a haircut during care conferences and in conversations with various staff members. Despite these repeated requests, there was no documentation that the resident was placed on a consistent haircut schedule until several months later. The representative eventually submitted a formal grievance after four months of unsuccessful attempts to resolve the issue informally. Staff interviews confirmed that concerns raised during care conferences were not escalated through the formal grievance process unless specifically requested by the resident or representative, and that the staff member responsible for social services was still learning the grievance process at the time. The facility's own policies required prompt investigation and resolution of grievances, with findings to be communicated both verbally and in writing to the complainant. However, the grievance process was not initiated until a formal grievance card was submitted, despite earlier verbal and written requests. The administrator and staff acknowledged that concerns raised in care conferences should have been addressed through the grievance process, and that communication with the resident's representative regarding the status of the request was lacking.