Failure to Log and Address Resident Grievance About Missing Personal Items
Penalty
Summary
The facility failed to honor a resident’s right to voice grievances and to ensure that a grievance regarding missing personal items was reported, logged, and resolved according to policy. Nursing documentation dated 3/20/25 by an RN (V12) recorded that resident R5 stated he had clothes and money missing and that no one was doing anything about it. During a later interview, the RN stated she documented the note on 3/30/25 and indicated that her usual practice when a resident reports missing items is to report them to the social services staff member (V9), but she could not recall whether she actually reported R5’s missing items to V9. In a separate interview, V9 stated that when a resident reports missing money or clothes, she spends 48 hours attempting to locate the items and, if unsuccessful, files a grievance form and replaces the items, but she was not aware of R5’s report of missing items. Review of the facility’s Grievance Complaint Log from January 2025 through October 2025 showed no grievance filed for R5’s missing clothing or money, despite the resident’s report. The facility’s undated Grievance/Complaint Policy states that residents have the right to voice grievances without discrimination or reprisal, that prompt efforts will be made to resolve grievances, that the disposition of grievances will be recorded on the grievance and complaint log, and that grievances will have a disposition within seven working days of being filed. This deficiency centers on the facility’s failure to ensure that R5’s grievance about missing clothes and money was communicated to the appropriate staff, entered into the grievance log, and processed in accordance with the written grievance policy.
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