Failure to Provide Prompt Grievance Resolution and Written Decision
Penalty
Summary
The facility failed to ensure prompt resolution of a grievance and did not provide a written decision to the complainant, as required by its grievance policy. A family member of a resident who had multiple complex medical conditions, including congestive heart failure, diabetes, chronic kidney disease, and a recent amputation, raised concerns about the care provided after the resident was sent to the emergency room for a change in respiratory status and low blood sugar. The family member reported issues such as difficulty reaching staff for updates, concerns about staff communication during the resident's transfer to the ER, and dissatisfaction with the clinical response to the resident's acute episode. Although the grievance was documented and discussed in an impromptu meeting with facility leadership and clinical staff, the investigation was ultimately escalated to a reportable event. The facility's Grievance Officer attempted to contact the complainant by leaving a voice message but did not provide a written decision regarding the outcome of the grievance. The complainant confirmed in an interview that she had not received any follow-up or written response from the facility regarding her concerns.