Failure to Follow Up and Document Grievance for Missing Eyeglasses
Penalty
Summary
The facility failed to follow up on and document a grievance regarding a resident’s missing eyeglasses. The resident, who had moderate cognitive impairment, was dependent on staff for ADLs, medically complex, and required corrective lenses, was admitted in early October 2025 and discharged in late December 2025. The admission MDS and care plan documented that the resident wore glasses, and the demographic record photo showed the resident wearing eyeglasses. The resident’s caregiver reported the glasses missing to facility staff on multiple occasions beginning in early December, and was referred to Social Services, where a search of a drawer did not locate the glasses. At discharge, the glasses were still not found, and the discharging nurse reportedly told the caregiver that because the glasses were not on the inventory list, “then it didn’t happen.” The facility’s grievance logs from October 1, 2025 through January 31, 2026 contained no entry for the missing glasses. Multiple staff interviews showed inconsistent understanding and implementation of the grievance and lost-item processes. A nursing assistant stated that when something was reported missing, he would notify Social Services, look for the item, and complete a grievance form. The Social Services assistant stated that a “stop loss” form should be completed when items are reported missing, but did not recall anything about the missing glasses; the Social Services director recalled hearing the glasses were missing and looking for them, but believed they had been found and acknowledged that no stop loss form was completed. An RN stated that if an item was reported missing and not found, a grievance form should be completed and forwarded to administration, but did not recall the glasses being reported missing. The case manager reported notifying nursing staff twice in December that the glasses were missing and that they were never found or replaced, resulting in the resident paying a $20 co-pay for a new pair. The LPN who completed the discharge summary recalled reviewing the inventory list but did not recall being informed of missing glasses, and the DON stated that missing items should trigger a grievance form and follow-up, but was unaware of this incident. The survey cited WAC 388-97-0460 regarding honoring residents’ right to voice grievances without discrimination or reprisal and the requirement to establish and follow a grievance policy.
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