Failure to Document and Investigate Resident Grievances About CNA Care
Penalty
Summary
The facility failed to honor residents' rights to voice grievances without reprisal by not recording, investigating, or documenting grievances reported about a CNA. One resident with cerebral palsy, cognitively intact and dependent on staff for most ADLs, reported that a CNA refused to get her out of bed on a specific date, telling her it had to be done the CNA's way or not at all, and left her for second shift to get her out of bed. The resident stated she reported this interaction to the DON and to the Ombudsman but did not complete a grievance form because she could not write legibly and would need staff assistance; she also expressed concern that documents tend to disappear and preferred to complain to the Ombudsman. The DON reported having no reports about this CNA. The CNA acknowledged that the resident was upset when she was not gotten out of bed before the end of the CNA's shift and that the resident later told her she had spoken to the DON and did not want the CNA to help her anymore. Another cognitively intact resident with bilateral upper and lower extremity impairments, who requires staff assistance for ADLs and supervision with eating, reported that the same CNA did not follow rules and had previously been written up after leaving the resident’s roommate hanging alone in a full-body mechanical sling lift, as reported by a nurse. This resident stated she reported the incident to the DON and later described an episode where she refused care from the CNA one day, then allowed the CNA to transfer her the next day; during that transfer, despite the resident’s instructions on positioning, the CNA left her in the sling to go get help, later claiming inadequate training. This resident was unaware of any grievance form and found it easier to tell the DON. Multiple staff gave conflicting accounts of the grievance process and knowledge of complaints: the Administrator knew only that one resident had called the CNA “bad” and was unaware of the second resident’s grievance; a CNA trainer reported “a lot of complaints” from residents about the CNA’s speech, use of the full-body lift without a second staff member, and a political argument with a resident, which she said she reported to Human Resources. The Human Resource Director, Social Service Director, RN, and DON each described a process in which staff should complete grievance forms and report to social services or administration, but each denied having resident complaints about this CNA. The Ombudsman reported that residents feel that when they report grievances to staff, nothing gets resolved. Review of the facility’s grievance log for the relevant months showed no entries reflecting the concerns of the two residents about this CNA, despite the facility’s written form stating it is to be used to document any grievance or concern and the follow-up actions and results.
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