F0585

D

Failure to Investigate and Follow Up on Resident Grievance Regarding Pain Management Interaction

Richmond, Indiana Survey Completed on 02-04-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow its grievance policy and promptly investigate and resolve a resident grievance. On the morning of 1/24/26, a cognitively intact resident with chronic pain syndrome, frequent pain, a history of cerebral infarction, anxiety, impaired neurological status, and aphonia was at the nurse’s station upset about her pain medication, believing it was due. The resident, who primarily communicated via tablet and used a cane, attempted to get the attention of an RN who stated it was not time for the PRN pain medication. According to a CNA, the RN did not initially acknowledge the resident despite the resident pounding her cane on the desk and kicking it, and when the RN eventually responded, the RN did so without looking up at the resident. The CNA reported that the resident was very upset and assisted her back to her room.

The CNA completed a written grievance form that same morning and placed copies under the DON’s and ED’s doors. However, no one from the facility followed up with the CNA or the resident regarding the grievance. In interviews conducted days later, both the CNA and the resident confirmed that no follow-up had occurred. The DON also acknowledged that they had not followed up with the resident about the grievance. This inaction conflicted with the facility’s Resident and Family Grievance policy, which states that written complaints to staff or the Grievance Official are recognized forms of grievances, that the Grievance Official or designee will keep the resident apprised of progress toward resolution, and that a written decision including investigative steps and findings will be issued, with prompt efforts made to resolve grievances.