Failure to Document and Resolve Resident Grievance Regarding Staff Responsiveness and Professionalism
Penalty
Summary
The deficiency involves the facility’s failure to follow its grievance policy and to promptly address and resolve a resident’s grievance. The facility’s policy titled “Grievances/Concerns,” dated 8/25/2021, states that upon receipt of a grievance or concern, staff will initiate a grievance/concern form and document it on the Grievance/Concern Log, and that the department manager will notify the person filing the grievance of the resolution and/or status within 72 hours. Despite this policy, there was no grievance form or log entry for the concerns raised about staff responsiveness and professionalism, and no written resolution was provided within the required timeframe. The resident involved was originally admitted and later readmitted with diagnoses including sepsis and type 2 diabetes mellitus. A History and Physical dated 12/30/2025 documented that the resident had capacity to understand and make decisions, and a Minimum Data Set dated 1/02/2026 indicated the resident was cognitively intact. On 12/22/2025, during dialysis, the resident reported to the dialysis social worker that staff at the facility did not respond when assistance was requested and that staff behaved unprofessionally, including cursing while at work. The dialysis social worker documented contacting the facility’s Social Services Director (SSD) by phone that same day, with the resident present, and the SSD stated she would follow up with the resident upon her return to the facility. Subsequent documentation from the dialysis center dated 1/12/2026 showed that the dialysis social worker attempted to contact the SSD again, left a voicemail, and did not receive a response. The facility’s grievance/complaint log for December 2025 contained no entries for this resident, and the resident’s progress notes from 12/22/2025 to 1/13/2026 contained no documentation of the concerns or any follow-up. In interviews, the dialysis social worker reported that the resident stated no one from the facility had addressed her concerns, and the resident confirmed that no one had followed up as of 1/13/2026. The SSD stated she had no documented grievances for this resident, did not document verbal concerns because there were too many residents, did not initiate grievance forms unless specifically requested, and could not recall the issues brought to her attention, resulting in no grievance resolution being provided to the resident.
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