Failure to Initiate and Investigate Resident Grievance per Policy
Penalty
Summary
The deficiency involves the facility’s failure to follow its grievance policy and promptly investigate a resident’s complaint. Resident 1, who had intact cognition and required varying levels of staff assistance for activities of daily living, was admitted with diagnoses including diabetes mellitus with diabetic nephropathy, chronic kidney disease, and an anxiety disorder. On the morning of 3/4/2026, an incident occurred between Resident 1 and Licensed Vocational Nurse 1 (LVN 1) at approximately 6:30 a.m. Later that morning, at 8:36 a.m., Resident 1 emailed the Director of Nursing (DON) describing the incident and expressing that LVN 1’s response was not acceptable and was wrong. By 3/6/2026, Resident 1 reported that no facility staff had asked about the incident, and no one had explained whether the incident had been investigated. Record review and staff interviews confirmed that the grievance was not processed or investigated in accordance with facility policy. The DON acknowledged receiving the resident’s email on the morning of 3/4/2026 and stated that the Social Services Director (SSD), who was responsible for filing grievances, had been verbally informed. However, review of the facility’s Grievances and Complaints binder showed that the grievance had not been filed and no investigation had been initiated. The Administrator confirmed that the grievance should have been entered into the grievance filing system and that an investigation should have been started. The SSD also confirmed that the required Complaint/Grievance form had not been used to initiate the grievance process and that no investigation had begun. This was inconsistent with the facility’s written policies, which state that residents have the right to voice grievances without discrimination or reprisal and that the Grievance Officer must conduct an initial investigation within 24 hours of receiving a grievance, using prescribed forms.
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