Failure to Maintain Effective Grievance Process and Follow-Up
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective grievance process that honored residents’ rights to voice grievances and receive prompt resolution. The facility’s written Grievance and Missing Property policy stated that residents, representatives, and families could present grievances to any staff member, that grievances would be documented on a grievance form, reviewed by the IDT within 10 working days, and that residents and representatives would be notified of the resolution. However, a grievance filed by Resident #44, who was documented as cognitively intact on a quarterly MDS dated 1/6/26, was not investigated or resolved. The resident reported filing a grievance on 1/5/26 regarding an incident in the 200 hall shower room and stated they had not heard back from the facility and felt that no one cared. Review of the grievance book showed a grievance form dated 1/5/26 with the resident’s name and a description of the shower room incident, but the sections for investigative findings, resolution, results reported to, and completion by the due date remained blank. Additional evidence showed systemic issues with the grievance process. During a resident council meeting, all five resident council representatives reported that staff very seldom contacted residents after grievances were filed and that it took months to hear back. Observations showed no grievance forms available in the lobby or on the 200 hall, and the Admissions Coordinator stated there used to be grievance forms and locked boxes on each floor and in the lobby but did not know what happened to them. An LPN and a CNA both reported they were not familiar with the grievance process and only informed the charge nurse of resident concerns. The Social Worker, newly designated as the Grievance Official, stated she was not aware of Resident #44’s grievance, and the Administrator also reported being unaware of that grievance, despite both indicating an expectation that grievances be investigated and resolved within five days and that residents and families have free access to grievance forms and a secure submission box.
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