Failure to Follow and Document Grievance Process for Resident Care Concerns
Penalty
Summary
The deficiency involves the facility’s failure to follow its grievance policy and to document grievances and prompt efforts to resolve them for a resident whose Activated Health Care Power of Attorney (AHCPOA) raised multiple concerns. The facility’s Grievance Program policy dated 5/15/24 states that grievances, defined as formal written or verbal complaints when prompt bedside resolution is not possible, must be documented on Comment/Concern Forms, routed to the grievance official, listed on the tracking log, discussed as warranted, and investigated accordingly. The policy also requires written grievance decisions to include dates, a summary of the grievance, corrective actions, and the date the written decision was issued to the complainant. The resident was admitted with diagnoses including cerebral infarction without residual effects and dysarthria/anarthria, and was on hospice services upon admission. Surveyors reviewed email communications from the AHCPOA to the Nursing Home Administrator (NHA) that listed specific concerns about the resident’s care, including the resident wearing dirty clothes, a full laundry bag, an unclean or unshaven face, a very red right eye needing more frequent eye drops, being found sitting unattended in the dining room while calling out for something to drink, lack of a mid-morning snack, difficulty obtaining coffee or juice, no juice cups in the room, eyeglasses found in the trash, and absence of hearing aids. When surveyors reviewed the facility’s grievance log, no grievance entry for this resident was found. In an interview, the NHA stated that when a grievance comes to her, she typically initiates a grievance form, works through what is needed, and follows up with the resident or family. However, regarding these concerns, the NHA acknowledged that due to the repetitive nature of the issues, she considered them part of day-to-day care rather than grievances, did not complete a grievance form, and had no documentation of investigation, follow-up, or resolution for the concerns raised, despite recognizing that she should have done so. As a result, the facility did not follow its grievance process.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.