F0585

D

Failure to Maintain Complete and Timely Grievance Documentation for Resident and Family Complaints

Buffalo, Missouri Survey Completed on 03-11-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement a complete and consistent grievance process, including timely documentation of grievances, follow-up steps, and resolutions for a resident and the resident’s family member. The facility’s grievance policy states that residents or their representatives may register complaints or grievances without fear of reprisal, and that grievances include complaints about care, abuse or neglect, and other issues that are not resolved at the time of the complaint by staff present. The policy further requires that unresolved complaints be escalated to supervisors, the Patient Advocate, and the Administrator as needed, and that the Patient Advocate maintain a log of complaints and grievances, with written notice to the complainant at the completion of the investigation, including steps taken, results, and date of completion.

The resident involved had been admitted with a diagnosis including a fracture of the neck of the left femur and had intact cognitive skills, requiring partial to moderate assistance with toileting, showering, bathing, and personal hygiene. A nurse’s progress note documented that the resident’s family member complained to a CNA that the resident had not received breathing treatments that day and objected to the resident wearing a brief instead of a pullup. The nurse noted that management and social services were not available in the building at that time, and when the nurse later asked the family member if there were any issues needing resolution, the family member stated that everything was fine. Subsequently, the Social Services Director (SSD) documented receiving an email from the family member expressing concerns about the resident’s care, including breathing treatments and use of briefs, as well as missing personal items such as lotion, Kleenex, a turquoise ring, and a watch. The SSD shared the email with the Administrator and DON and noted that a staff member reported the family member had thrown wipes at them, and that the plan was to remove that staff member from providing care to the resident and to offer moving the resident to another hall.

The facility’s complaint/concerns log recorded a complaint from the resident’s family member about missing rings, lotion, and a watch, and noted that replacement items were provided, but did not document any discussion with, or signature of, the resident or the family member who filed the grievance. A later progress note by the SSD, created weeks after the event date, described responding to another email from the family member about missing items and documented that the facility replaced multiple rings, lotion, and a watch, and informed the resident and family, but again did not reflect complete grievance documentation as required by policy. Another progress note by the DON described contacting the family member regarding concerns from the prior night, with the family member referring the DON to staff and a formal grievance before hanging up; however, this grievance was not entered on the facility’s grievance log. Interviews with the CNA, SSD, DON, and Administrator confirmed that the SSD was responsible for grievances, that staff were expected to report complaints to her, and that grievance forms and logs existed, but also revealed that the SSD did not document resolutions on the grievance log, did not have a form with a written resolution to return to complainants, and did not know the outcome of an investigation into a reported $10 payment from the resident to an aide. The DON acknowledged that resolutions of grievances were not documented, and the Administrator stated he expected documentation of who was spoken to, whether the grievance was resolved, and the response to the complainant, but these elements were missing, demonstrating the facility’s failure to maintain a complete grievance process for the resident’s grievances.

Additional information from interviews further supports the incomplete grievance process. The SSD stated that if residents spoke with staff about complaints, staff should email or inform her, and that she reported grievances to the Administrator and DON and attempted to respond within 24 hours. She also reported receiving an email from the resident’s family member about an aide receiving $10 from the resident and said she informed the Administrator, but she did not document the resolution on the grievance log and did not know the results of that investigation. The DON described that grievances should be taken to social services, that grievance forms were available in a binder, and that staff discussed grievances in morning meetings with department heads, but she admitted she did not document grievance resolutions even though she believed they probably should be documented. The Administrator indicated that SSD should document who she talked with, whether the grievance was resolved, and the date, and that staff should document the response to the person who filed the grievance, yet he was not aware of the reported $10 payment. These documented omissions and inconsistencies in logging grievances, documenting follow-up steps, and recording resolutions for the resident’s and family member’s complaints constitute the identified deficiency in the facility’s grievance process.

Overall, the events show that multiple complaints and concerns from the resident’s family member regarding care issues, missing personal items, and a possible financial concern were not consistently or fully documented as grievances in accordance with the facility’s own policy. The grievance log lacked entries for at least one formal grievance referenced by the family member, and existing entries did not include documentation of discussions with the complainant or confirmation of resolution. Staff interviews confirmed that there was no standardized form with a documented resolution returned to the complainant and that outcomes of certain investigations were unknown or not recorded. These actions and inactions demonstrate that the facility did not have a complete grievance process in place for this resident, as required by its policy and regulatory expectations.