Failure to Implement Grievance Process for Resident Care Concerns
Penalty
Summary
The facility failed to implement its grievance process for one resident who expressed care concerns. The resident, who had intact cognition and diagnoses including fractures and heart disease, was care planned to require mechanical lift transfers due to mobility issues. The resident reported via email to the DON and administrator that he sustained a painful bruise during a transfer to a shower chair, which resulted in significant pain and limited his ability to get out of bed for over two weeks. He also reported repeated denials of requests to be transferred to his recliner for lunch and concerns about a missing pillow needed for proper positioning. Despite these concerns being communicated directly to facility leadership, the resident did not receive a response from the DON or administrator. Interviews confirmed that the resident's concerns were not formally documented or processed as grievances, as required by facility policy. The administrator acknowledged receipt of the resident's email and stated that the DON was supposed to handle the issue, but no grievance was written up. The facility's grievance policy requires prompt acknowledgment, investigation, and communication of findings to the resident, none of which occurred in this case. The lack of response and failure to follow the grievance process resulted in the resident's concerns not being addressed in a timely or appropriate manner.