F0585

D

Failure to Log and Process Resident Grievance Regarding Missed Medical Appointment

Atco, New Jersey Survey Completed on 01-09-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that its method for filing and handling grievances was consistent with its own grievance policy and actual practice. A resident with a history of hemiplegia and hemiparesis following a cerebral infarction, epilepsy, and a severely impaired cognition (BIMS score of 2/15) reported to surveyors that they had anticipated a follow-up brain surgery appointment scheduled for 12/29/25 due to persistent deep head pain radiating from the base of the neck to the area of a right hemi craniotomy. The resident stated that no one from the facility came to get them dressed and ready for the appointment and confirmed they did not refuse to go. The resident was dependent for upper and lower body dressing and did not exhibit behaviors such as rejection of care per the most recent MDS.

Staff interviews and record reviews showed that the facility did not document or process the missed appointment as a grievance, despite the resident and the resident representative voicing concerns. The Social Services Director, who served as the grievance officer, provided grievance logs for several months that contained no entries for this resident, and no grievance report was initiated. The CNA recalled that the resident had a missed appointment and that she was not informed to get the resident ready; she also stated that the resident’s name was not on the appointment list on the white board. The CNA further reported that the resident representative came into the facility visibly upset about the missed appointment and that both the ADON and DON were aware of this.

The ADON stated she recalled the missed appointment and that the resident representative arrived visibly upset and yelling in the hallway, but she believed the resident had refused the appointment and acknowledged that she did not speak with the resident or family about the incident and did not think a grievance was made. Review of the progress notes with the ADON confirmed there was no documentation that the resident refused the appointment, no follow-up appointment was made, and the physician was not notified of the missed appointment. The DON confirmed she only learned of the missed appointment when the resident representative arrived angry and that she did not initiate a grievance. An investigation file contained only a single signed statement from an LPN indicating the resident refused to go after transport arrived, and a trip order showed the transport was cancelled by the same LPN with the reason documented as “appointment cancelled.” The facility’s written grievance policy stated that residents and their representatives have the right to file grievances orally or in writing and that the administrator and staff would make prompt efforts to resolve grievances and inform the complainant verbally and in writing of the findings and corrective actions, but no grievance was initiated or resolved for this resident’s complaint.