Failure to Initiate and Document Grievance for Resident Care Concerns
Penalty
Summary
The deficiency involves the facility’s failure to promptly and properly process and document a resident grievance in accordance with its grievance policy. A resident admitted with cerebral infarction, major depressive disorder, and left-sided hemiplegia had an admission MDS showing a BIMS score of 15/15, indicating no cognitive impairment, and care plan needs including incontinence of bowel and bladder, frequent checks for wetness and soiling, and extensive assistance with toileting. During observation and interview, the resident reported having diarrhea for a week, difficulty obtaining timely assistance, needing to bang on the wall for help, and sometimes not having the call light within reach due to her paralysis and staff placing it on her left side. The resident also reported that a male and a female CNA were verbally aggressive, that they woke her at 3:00 AM insisting on showering her, and that she was manhandled during the shower. She stated she preferred bed baths and use of a bedpan, and that the female CNA spoke to her in a loud, demeaning tone, gave her a hard time about using the bedpan and receiving bed baths, and wanted her to use briefs despite her objections. The resident stated she had expressed these concerns to different nursing staff. A CNA reported that a few weeks earlier the resident had told her some staff were rough and gave her a hard time about using the bedpan or receiving a bed bath instead of a shower; the CNA stated she reported these concerns to a charge nurse but could not recall which nurse. Later, in the presence of LVN B, the resident repeated the same concerns she had shared with the surveyor, including that a Black CNA talked loudly to her, gave her a hard time about using the bedpan, did not want to provide bed baths, and that staff took a long time to respond when she asked for help, as well as mentioning being manhandled during a shower. LVN B acknowledged being aware of these concerns and stated he was required to write a progress note and follow the grievance process, but he did not complete a grievance form or enter a progress note regarding the resident’s complaints. The Administrator, identified as the grievance officer per facility policy, reported not knowing about the resident’s concerns, and the DON confirmed that there was no progress note from LVN B documenting his conversation with the resident and that he was new to LTC and may not have been familiar with the grievance process. This failure to initiate and document the grievance process for the resident’s reported concerns constitutes the cited deficiency.
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.