F0585

D

Failure to Follow Grievance Policy and Address Resident’s Ongoing Concerns

Bad Axe, Michigan Survey Completed on 03-11-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow its grievance policy and properly address a cognitively intact resident’s concerns that were voiced through the State Ombudsman. The resident was admitted with multiple diagnoses including orthopedic aftercare following surgical amputation, depression, anxiety disorder, paranoid personality disorder, and post‑traumatic stress disorder, and had a BIMS score of 15/15, indicating intact cognition. Functionally, the resident required varying levels of assistance with ADLs, including dependence for toileting hygiene and transfers. During an Ombudsman visit, an Elder Advocate witnessed staff responding inappropriately to the resident’s call light, including shutting off the call light, stating they were too busy, rolling their eyes, raising their voices, leaving, and not returning to assist. These concerns were relayed by the Ombudsman to the Administrator via email.

In subsequent interviews, the resident reported that these issues had not been resolved and that problems with staff response to call lights and staff behavior continued. The resident described staff answering the call light and telling her they were taking care of other people, turning off the call light and not returning, instructing her to go in her brief and stating they would come back, and not returning. The resident also reported concerns about therapy not working enough on transfers to the toilet/bedside commode and being told she could not keep her own glucometer at the facility. The resident stated she preferred to communicate concerns through the Ombudsman rather than directly to the Administrator, DON, or Unit Manager, and reported that staff had not offered to help her write a concern form, had not provided her with concern or grievance forms, and had not given her any written documentation or resolutions related to the concerns she raised through the Ombudsman.

Staff interviews showed that the facility did not document or process these concerns in accordance with its written Care Program grievance policy. Nursing staff acknowledged awareness of some issues, such as dressing changes, therapy participation, and behavioral concerns, but reported they had not completed grievance or concern forms, with one nurse characterizing the resident’s complaints as normal behavior and personality. The Ombudsman reported that the facility had not offered to write out a complaint form or Visitor Assistance Form and was not aware that any such forms had been completed or offered as an option. The Administrator confirmed that no concern forms had been completed for this resident’s issues, explaining that concerns were being addressed in real time and were not considered ongoing, despite the policy requiring that oral concerns be documented on a Resident, Family, Employee and Visitor Assistance Form, discussed in IDT, logged, and followed up to ensure satisfaction. As a result of not following the policy, the resident’s concerns were not formally documented, investigated, tracked, or evaluated for satisfaction as required by the facility’s Care Program.

The facility’s Care Program policy specifies that any concern or grievance, whether written or oral, should be documented on the Resident, Family, Employee and Visitor Assistance Form, acknowledged, investigated, discussed in IDT, and forwarded to the Administrator for logging and tracking in the facility’s QA log, with follow‑up within seven days to ensure the concern is addressed to the complainant’s satisfaction. In this case, the resident’s concerns communicated through the Ombudsman and directly to staff were not processed through this formal mechanism. The lack of documentation and use of the required forms meant that the concerns were not entered into the facility’s tracking and trending system, not formally investigated through the IDT process, and not subject to the required follow‑up evaluation for satisfaction, as described in the policy. This failure to follow the established grievance procedure led to the cited deficiency related to honoring the resident’s right to voice grievances and ensuring prompt, documented efforts to resolve them.