Failure to Honor Resident Grievance Rights and Document Complaint
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to voice a grievance and the failure to promptly investigate and document that grievance. Facility policy stated that any resident or representative may file a grievance orally or in writing, including anonymously, and that the grievance officer and staff would take immediate action to prevent further potential violations of resident rights while an alleged violation was being investigated. A resident who is continent and normally independent in using the restroom during the day reported that on the morning of January 8, 2026, an LPN entered her room to pass medications. When the resident stated she needed to use the restroom and her roommate requested a bedpan, the LPN instead obtained a bedpan, rolled the resident onto it, placed it under her, and left the room. The resident reported being left on the bedpan with the call bell on until she became tired and removed it herself. The resident stated she reported this incident the same day to the Admissions Director and the Social Worker and requested to speak with the Nursing Home Administrator (NHA). The Admissions Director reported that the resident told her she had been put on a bedpan and left there and that she wanted to speak with the NHA, but there was no documentation of this conversation or of notifying the NHA. The Social Worker also reported that the resident described the incident involving the LPN giving the bedpan to the resident instead of the roommate and then leaving, but the Social Worker had no documentation and could not recall if a grievance was filed. Review of the grievance log from November 2025 to the present showed no grievance related to this incident, and there was no documentation in the resident’s clinical record or facility records regarding the concern. The NHA acknowledged being made aware that the resident had a concern with an employee and briefly visited the resident, but had no documentation of the concern at that time. These omissions demonstrate that the facility did not follow its grievance policy or ensure the resident’s right to voice a grievance and have it addressed.
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