Failure to Document and Address Resident Grievances
Penalty
Summary
The facility failed to establish and maintain a system to ensure that resident grievances were properly initiated, logged, addressed, and resolved in a timely manner. One resident repeatedly verbalized multiple concerns and grievances regarding their care, including issues with pest control, the cleaning of linen and clothing after pests were found, and dissatisfaction with meal service, specifically being served cold meals. Despite these repeated complaints, there was no documentation of the grievances in the facility's grievance logs for the relevant months, nor any record of the concerns or meetings in the resident's electronic medical record. Interviews with staff confirmed that the resident had voiced numerous complaints, including missing or damaged clothing and ongoing dissatisfaction following a pest control incident. Staff members, including the social worker, resident care manager, and administrator, were unable to locate any grievance logs or documentation related to the resident's concerns. This lack of documentation and follow-up prevented the facility from identifying care trends and determining the effectiveness of any actions taken to resolve the grievances, resulting in the resident repeatedly reporting the same issues without resolution.