Failure to Investigate and Document Resident Grievance About CNA Conduct
Penalty
Summary
The deficiency involves the facility’s failure to follow its grievance policy and fully investigate a resident’s complaint about staff behavior. A cognitively intact resident with hypertension, reduced mobility, and lack of coordination reported that on one occasion, after using the call light for assistance, a CNA entered the room, yelled at her to stop using the call light, and stated that nurses did not like helping her because she used it too much. The resident stated she reported this incident and her concerns to the social worker and never heard anything further, noting that the CNA continued to work on her hall. Review of the facility’s grievance tracking log showed an entry dated for the resident’s concern involving the CNA, but the grievance binder contained no corresponding grievance documentation for this incident. During interviews, the Administrator stated that no resident or employee had brought concerns about this CNA to him and that he had not received any grievance from this resident. The DON similarly reported that no grievance regarding this CNA or an incident involving this resident had come to her and that she had never received anything about the incident. In contrast, the social worker stated she did complete a grievance form for the resident regarding the CNA yelling at the resident and discouraging call light use, and that, because it was a nursing concern, it should have gone to the DON. She acknowledged she did not know where the grievance document was, and that while the tracking log reflected the incident, the actual grievance form was missing from the binder. The facility’s policy stated that staff are encouraged to guide residents on where and how to file a grievance when they believe their rights have been violated, but the documented process steps described by leadership—review in morning meeting with the IDT, assignment to the appropriate department head, coordination of a resolution plan, and written documentation of actions and disposition—were not carried out or documented for this resident’s grievance.
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.