F0585

D

Failure to Follow Grievance Policy and Document Resolution of Care Concerns

South Milwaukee, Wisconsin Survey Completed on 02-18-2026

Penalty

No penalty information released

Summary

The facility failed to follow its grievance policy and ensure prompt resolution and proper documentation of a grievance related to a resident’s care. A resident with anoxic brain damage, acute respiratory failure with hypoxia, tracheostomy and gastrostomy status, morbid obesity, congestive heart failure, major depressive disorder, anxiety, and a BIMS score indicating coma was the subject of a grievance filed by the resident’s family/guardian. The written grievance documented concerns that the resident was not being turned as frequently as needed, had feces on the sheets, was not being checked on as often as the family desired, and that the tracheostomy might be infected. The grievance form noted that the SW and DON met with the guardian, that the family wanted the resident checked at a hospital for possible trach infection, and that the concern was marked as resolved with the family reportedly satisfied with the plan.

Despite the facility’s written policy requiring the Grievance Official to oversee the process, investigate, and issue a written decision including the steps taken, findings, confirmation status, and corrective actions, there was no evidence of follow-up or resolution beyond the initial notation on the grievance form. The current DON reported she had no additional information and could not locate any further documentation related to the grievance. The resident’s guardian later stated that the same concerns about turning, repositioning, checking on the resident, use of boots, and development of bed sores persisted and that no one addressed or changed anything after the grievance was filed. Surveyors found no additional information when the NHA and DON were notified of concerns regarding grievances.