Failure to Document and Address Resident Grievances per Facility Policy
Penalty
Summary
The facility failed to identify and document grievances as required by its own policy for a resident with Alzheimer's Disease and dementia, who had an activated power of attorney for healthcare. The resident's power of attorney (POA) voiced concerns to the facility's social worker regarding the resident being put to bed too early and not receiving prescribed eye drop medication. Despite these concerns being communicated multiple times, the social worker did not initiate or document grievances for these issues, as required by the facility's grievance policy. The facility's grievance policy states that any circumstance thought to be unjust and grounds for a complaint, including those related to care and treatment or missing property, should be documented and investigated. The policy also requires that all grievances and concerns be logged and investigated within five business days. However, review of the grievance log revealed that only issues related to missing property were documented, while concerns about care routines and medication administration were not entered as grievances. Interviews with the social worker and interim director of nursing confirmed that the concerns about early bedtime and missed eye drops were not documented as grievances. The social worker acknowledged the oversight, stating that a risk assessment was done for the medication issue and the care plan was updated for the bedtime concern, but no formal grievance was initiated. The interim director of nursing agreed that these concerns should have been documented as grievances according to policy.