F0585

D

Failure to Properly Investigate and Communicate Grievance Resolutions for Two Residents

Tampa, Florida Survey Completed on 03-18-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow its grievance policy and to appropriately receive, investigate, document, and communicate grievance resolutions for two cognitively intact residents. The Social Services Director (SSD) described a process in which residents obtain grievance forms from a pamphlet holder, submit them to SSD, and SSD then copies, logs, and routes them to the appropriate department for investigation and resolution, with follow‑up in three to five days. However, an LPN who had been working at the facility for a few weeks did not know the facility’s grievance process and only assumed a form was available somewhere. The facility’s written policy designated a Grievance Officer responsible for tracking grievances through conclusion, leading investigations, keeping residents apprised of progress, and issuing written grievance decisions that include specific required elements.

One resident, admitted with multiple mobility‑related diagnoses including a left patella fracture, muscle wasting, gait abnormalities, and a BIMS score of 15, had care plans indicating a need for assistance with ADLs and toileting and a risk for falls, with interventions to assist with all ADLs and toileting and to use the call light for assistance. This resident reported long waits for CNAs to respond to call lights and stated they sometimes went to the bathroom without assistance. A grievance form completed by the Housekeeping Director documented that the resident stated it was hard to get a CNA to help them to the bathroom, but the written “action taken” and “final resolution” on the form focused on the dining room being closed due to an RSV outbreak and indicated the resident was satisfied. The resident and a family member later stated the resident had never been to or wanted to go to the dining room, did not leave the bed except for therapy, and that no one had come to discuss the grievance resolution with them, contradicting the grievance form’s notation that the resident was satisfied. The SSD stated the resident had wanted to go to the lunchroom bathroom and that SSD had explained they could not due to RSV, and also stated there was no concern about the resident’s memory because of the BIMS score of 15.

The same resident’s family member reported multiple issues, including finding the resident’s pajamas soiled and call lights not being attended, and stated the facility would say they would file a grievance but nothing would be done. The family member specifically believed there should have been a grievance filed for an incident on a particular date, but review of the grievance log showed no grievances for that date or throughout the resident’s stay other than the one about needing CNA assistance to the bathroom. The Housekeeping Director confirmed that the resident had complained about long waits for call light response for bathroom assistance during angel rounds and did not know where the dining room portion of the grievance form came from, and also stated they did not speak to residents about resolutions. The DON stated that, regardless of which department head did angel rounds, SSD was to conduct the resolution, and that only the administrator or designee needed to sign the grievance, while SSD stated there was no section for other department heads to sign and that SSD always conducted follow‑ups after department heads resolved grievances.

Another resident, admitted with polyarthritis, morbid obesity, anxiety, sleep apnea, muscle weakness, muscle wasting, chronic pain syndrome, and a BIMS score of 15, had care plans indicating risk for functional decline in mobility and self‑care, with an intervention to encourage use of the call light, and risk for complications related to bowel and/or bladder incontinence, with an intervention to provide incontinence care with each episode. This resident had a grievance form stating they voiced concern about not getting changed in a timely manner, with the documented action that staff were educated on answering call lights timely and a final resolution stating the resident was satisfied, signed off by SSD. In interview, the resident reported waiting two and a half hours for a brief change on one night and an hour and a half on another night, with staff coming in to turn off the call light and saying they would be right back, and believed there might be an issue with night staffing. During the interview, SSD entered the room and asked if the resident needed anything; after SSD left, the resident stated they had never seen SSD before and that SSD had not come in to discuss the grievance resolution, and they did not know what was done with the follow‑up or receive the form back. These accounts show that the facility did not consistently follow its own grievance policy requirements for investigation, documentation, and communication of written grievance decisions to residents.