Failure to Promptly Address Grievances and Missing Personal Property
Penalty
Summary
The deficiency involves the facility’s failure to promptly initiate, investigate, and resolve resident grievances related to missing personal property, as required by its grievance policy and theft/loss prevention program. The admission agreement stated the facility must listen to and act promptly on grievances from residents and their families, and the theft/loss program required a written inventory of personal property upon admission. Despite these requirements, multiple high-value and functionally important items purchased for residents, including specialized phones and an Echo device, were not inventoried when received and were later reported missing without timely grievance processing. For one resident, the representative reported that two phones and an Echo device purchased to assist with hearing were missing. Invoice receipts showed a white landline phone ordered and shipped to the facility, an Echo with stand ordered and shipped to the facility, and a Clarity amplified cordless phone delivered to the facility’s front desk. The representative emailed the social services aide about the missing Echo but received no response, and the facility was still unable to locate the items weeks later. When the resident’s room was observed, there were no cordless or landline phones and no Echo present. Review of grievance logs for several months showed no entry for this resident’s missing items during the period when the concerns were initially raised, and inventory sheets dated after the items were delivered did not list the two phones or the Echo. For another resident, an amplified cordless landline phone was ordered and delivered to the facility’s front desk, but the resident’s inventory list was blank and did not include the phone. The grievance logs for multiple months did not list a grievance for this resident’s missing phone during the time it was reported missing. Later observation showed the amplified cordless phone at the resident’s bedside, charged and turned on, but this was after the period when the grievance had not been documented or promptly addressed. The social services director later stated that grievances for both residents were resolved but was initially unable to locate or provide the grievance forms, indicating that the grievances were not promptly documented and processed in accordance with the facility’s grievance policy and theft/loss prevention program.
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