Failure to Implement Grievance Process for Resident’s Missing Tablet
Penalty
Summary
Facility staff failed to follow the facility’s grievance protocol when a cognitively intact resident reported a missing tablet. The facility’s undated Grievance Protocol policy stated that the purpose of the Grievance/Complaint Report and Grievance Log is to provide a written record of each resident and family concern and to ensure proper follow-up through appropriate disciplines, with the Social Service Director (SSD) responsible for the program and the administrator ultimately responsible for its implementation. The policy specified that a Grievance Complaint Report should be used for situations involving lost or unlocatable resident articles, including ongoing concerns about lost items and laundry issues, and that the SSD would obtain the original report and forward a copy to the appropriate discipline. Review of the grievance log showed an entry indicating the resident had reported a missing tablet and that staff were searching for the item, but there was no documentation that a grievance form had been completed or that a copy had been provided to the resident or guardian. During interviews, the resident stated the tablet had been missing for about a month, that he/she had reported it to an unknown staff member, and that he/she had not been given a resolution. The SSD reported that staff were directed to report grievances to him/her or to direct residents to do so, but acknowledged not considering a missing item to be a grievance and therefore did not complete a grievance form or provide a copy to the resident. The SSD confirmed the tablet was not found or replaced and that the resident had not been provided with a resolution, and also stated being newer to the position and not recalling training on the grievance process. The administrator stated the SSD was responsible for completing a grievance form, providing it to the resident, and giving a resolution within twenty-four hours, and acknowledged that the resident’s tablet had not been replaced and that the resident should have had a resolution but it “slipped through the cracks.”
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