Failure to Timely Initiate and Investigate Resident Grievance Regarding Missing Personal Items
Penalty
Summary
The facility failed to initiate a grievance report in a timely manner after a resident reported missing personal items, specifically two jackets. The resident communicated the loss to multiple staff members and the Ombudsman, who then notified the Administrator on the same day. Despite this notification, the Administrator did not recall or document the grievance until nearly two months later, and no action was taken to resolve the issue during that period. The resident expressed ongoing distress and uncertainty about the missing items, stating that she had informed several staff members and the Ombudsman, but did not see any resolution or follow-up until the survey was in progress. Facility policy requires all staff to report grievances to the Social Service Director, who serves as the grievance official, and mandates that grievances be investigated and resolved within five working days. However, the Social Service Director was not informed of the grievance until the time of the survey, and the grievance was not brought to the daily Quality Assurance meeting as required. The delay in reporting and investigating the grievance resulted in a significant lapse in addressing the resident's concern in accordance with facility policy.