Failure to Document and Follow Up on Resident Grievance Regarding Bathing
Penalty
Summary
The facility failed to follow its grievance policy and procedure by not documenting and tracking a resident's care-related complaint as a formal grievance. The facility's written policy required that grievances about care and treatment, staff behavior, and other concerns be written on a grievance/complaint report form, entered into a grievance log with the disposition, and followed up after resolution to ensure effectiveness. A resident with diagnoses including unspecified focal traumatic brain injury, dementia with behavioral disturbance, and persistent mood affective disorder voiced a concern during a care plan meeting that he was not receiving baths in a timely manner. This concern was documented in a progress note, which indicated that the issue was addressed with the CNA supervisor. Review of the grievance logs for several months showed no entries for this resident, despite the grievance officer stating she considered the resident's bath concern to be a grievance. She acknowledged that she notified the CNA supervisor but did not complete a grievance form, did not log the grievance, and did not follow up with the resident to ensure the concern was resolved, contrary to facility policy. The administrator confirmed that issues with care, including bath concerns, were considered grievances and that the grievance officer should have completed the required documentation and follow-up. During observation, the resident was seen in his room eating breakfast in his wheelchair, and the room had a strong smell of urine, but there was no evidence in the grievance documentation that his earlier concern about bathing had been processed according to policy.
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