Failure to Properly Investigate and Document Resident Grievance
Penalty
Summary
The deficiency involves the facility’s failure to follow its grievance investigation and documentation procedures for a cognitively intact resident who filed a grievance about staff conduct during care. The resident, who had chronic kidney disease, anxiety disorder, and COPD, required substantial to maximal assistance with toileting, bathing, dressing, and transfers. A Complaint and Grievance Report (CGR) form documented that during an evening shift, an unidentified CNA pulled a sheet from under the resident and threw it on the floor during care. The Social Services Director (SSD) received the grievance report later and noted that the resident could not recall the CNA’s name, and the SSD endorsed the report to the Director of Staff Development (DSD) and nursing for follow-up. When surveyors reviewed the CGR form with the SSD, they found that key sections were left blank, including the steps taken to investigate the grievance, the summary of pertinent findings or conclusions, and the date the grievance decision was confirmed. The SSD acknowledged that the nursing department was responsible for follow-up interviews and documentation of the investigation, and that the CGR should have included details such as the in-service topic discussed with the CNA and a summary of the investigation. The SSD further acknowledged that she did not review or follow up on the investigation, did not complete the missing sections, and did not explain to the resident the steps taken to investigate the grievance. Additional interviews with the DON and DSD confirmed that the investigation was incomplete and not documented in accordance with facility policy. The DON stated that the CGR form lacked documentation of the steps taken to investigate and any attached investigation report, and that required elements from the grievance policy—such as date and time of the alleged incident, circumstances, location, names of witnesses and their accounts, and recommendations for corrective action—were not recorded. The DSD similarly stated that the nursing department was responsible for follow-up interviews and documentation, but the CGR form remained incomplete, missing information such as names of staff interviewed, the resident’s name, interview times and dates, and names of involved persons. The SSD later stated that the initial investigation had incorrectly identified the CNA involved, further demonstrating that the grievance investigation process and documentation were not properly carried out for this resident.
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