Failure to Operationalize and Follow Grievance Process
Penalty
Summary
The facility failed to ensure a comprehensive and effective grievance process for residents, resulting in multiple grievances being mishandled or inadequately addressed. Several residents and their representatives reported grievances related to room changes without notification or consent, safety concerns regarding unlocked doors, and lack of response to complaints. In some cases, staff did not complete required grievance forms or investigations, and documentation was either missing or completed only after surveyor requests, sometimes with backdated signatures. Specific incidents included a resident being left in bed naked and in soiled conditions overnight by a CNA, with no documented investigation or resolution provided to the resident. Another resident reported being yelled at and mistreated by a CNA, with the only documentation being a note that the resident felt safe after the CNA was no longer working at the facility. Additional grievances involved unacceptable staff-to-patient ratios, delayed care, and improper wound care, with documentation showing only minimal follow-up and some staff being reported to the State Survey Agency after the fact. There were also reports of a resident falling and subsequently being mistreated by staff, including having essential items removed from their reach and being yelled at. Multiple residents filed grievances about rough and mean treatment by a particular CNA, with at least ten residents affected. The facility's policy required thorough investigation, documentation, and reporting of grievances, especially those involving abuse or neglect, but these procedures were not consistently followed, and some grievances were not reported to the State Survey Agency as required.