Failure to Investigate and Resolve Resident Grievances
Penalty
Summary
The deficiency involves the facility’s failure to follow its grievance policy and to thoroughly investigate and resolve grievances for three cognitively intact residents. For one resident with complete paraplegia, type 2 diabetes, class 3 obesity, neurogenic bowel and bladder, and pressure injuries, a family member submitted a written grievance on 1/7/26 regarding a missed suprapubic catheter placement appointment due to unscheduled transport, worsening of an existing pressure injury and discovery of another pressure injury in the hospital, lack of appropriate wound care supplies, repeated observations of the resident in a soiled brief with stool dripping on the floor, and unreturned phone calls from staff. The grievance form in the facility’s file was incomplete, and the Registered Nurse Consultant confirmed that although the concerns were reported, the facility did not complete an investigation or follow-up on the grievance. Another resident with hemiplegia and hemiparesis following a stroke, who was dependent on staff for showers and had intact cognition, reported filing a grievance in September 2025 about not receiving a shower for three weeks. The resident did not recall anyone following up about the concern and stated that a family member who worked at the facility reported the missing showers to the facility. The family member confirmed reporting that the resident was not receiving showers and that the resident’s showers resumed afterward, but did not recall whether an investigation occurred. When surveyors requested documentation of a grievance related to this issue, facility leadership could not produce any grievance documentation or investigation related to the resident’s shower complaints. A third resident, who had COPD, morbid obesity, peripheral vascular disease, a history of pulmonary embolism, and dependence on supplemental oxygen and staff assistance for most ADLs, reported that on a night in January 2026, an RN attempted to administer medication with a spoon without acknowledging the resident’s ability to self-feed and need for oxygen tubing change. The resident stated that when the RN returned later and again attempted to give medication, the RN said, “I’m not going to take your shit,” then changed the oxygen tubing and left. The resident reported this incident to an RN and a CNA on the following morning shift. Both staff members confirmed the resident’s report and stated they relayed the concern to a nurse or supervisor, and an LPN acknowledged being told the resident believed the RN had sworn at them and reported it to a supervisor. The RN Consultant confirmed the concern was reported but stated the facility did not complete an official investigation or file a grievance, and there was no related progress note in the resident’s record.
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