F0585

D

Failure to Investigate and Document Resident Grievance Against Staff Member

Durham, Connecticut Survey Completed on 02-19-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow its grievance policy and ensure a resident’s complaint about a staff member was referred to the designated grievance official, investigated, and documented with findings and resolution. Resident #1 had diagnoses including traumatic brain injury, dementia with behavioral disturbances, conduct disorder, anxiety disorder, and psychosis, and was assessed as having severely impaired cognition, requiring substantial assistance with mobility and total assistance for personal hygiene, toileting, and transfers. The resident’s care plan identified impaired decision-making, a history of making allegations and inappropriate comments toward staff, angry outbursts, and poor social boundaries, with interventions focused on calm, firm approaches, redirection, and support. A behavior note by the Director of Social Services documented that on 2/13/26 the resident was heard making inappropriate comments toward a staff member assisting other residents, which disturbed other residents; the Director of Social Services met with the resident, discussed the behavior, and provided emotional support and reassurance.

On a later interview, Resident #1 stated that NA #5 was mean and that they did not want NA #5 near them, though the resident could not provide specific examples or recall the earlier incident. NA #5 reported being the resident’s primary NA on the day shift until being informed by the DON on 2/13/25 that the resident had made generalized allegations against him and that he would no longer be assigned to the resident; NA #5 stated he had never had issues with the resident, the resident had never complained directly to him, and he was not asked to provide a written statement. The Director of Social Services stated she was not aware that the resident had made a complaint about NA #5 beyond the initial behavior incident and acknowledged that a grievance should have been initiated and investigated. The DON reported that after the 2/13/26 incident, the resident told her he was upset because NA #5 was a “chump,” but she did not obtain further details, did not document the complaint as a grievance, did not obtain statements, did not conduct or document an investigation or rationale for determining the complaint unsubstantiated, and did not notify the Director of Social Services. This was inconsistent with the facility’s grievance policy, which designated the Social Worker as the grievance official responsible for preparing a written investigative report and documenting findings and resolution.