Failure to Promptly Address Resident Grievances on Missing Items, Smoking, and Alleged Neglect
Penalty
Summary
The deficiency involves the facility’s failure to promptly respond to and resolve resident grievances, particularly regarding missing personal items, smoking concerns, and an allegation of neglect. A family member reported that a television purchased for a resident and brought to the facility went missing after the Maintenance Director removed it to address cable connection issues and replaced it with a facility-owned TV. The Social Service Assistant acknowledged receiving an email from the family about the missing TV but did not complete a grievance report or follow up, and the Maintenance Director confirmed the TV disappeared and that he did not notify the family. Multiple residents reported missing personal clothing, stated they had filed grievances, and indicated that their items had neither been found nor replaced, and that they had not received any response to their grievances. Record review of grievances over specific dates showed that missing personal item grievances had not been acted upon. The Social Services Director stated that grievance follow-up should occur within seven days, but the Administrator explained that there was no response documented on the grievance forms because the grievances had not been resolved and the facility was still looking for the items. The Laundry Director reported that she had not responded to approximately two months of grievances due to short staffing and lack of time to review them. Resident council minutes and interviews revealed ongoing concerns about smoking schedules and the reduction in the number of smoke breaks, with one resident stating that the Administrator had changed smoking times and frequency without discussing it with residents at council and that repeated concerns about smoking had not received a response. A grievance form documented a family member’s concern that a resident had been put to bed in the afternoon and left in day clothing and shoes all night after a CNA failed to return to change the resident into night clothes. The Social Services Assistant stated she wrote this grievance during a care conference and handed it to nursing but did not follow up on the response or on communication with the family, and later acknowledged she should have followed up since she initiated the grievance. The Administrator reported that he had spoken with a resident about volunteering to supervise smokers and about safe-smoker testing and communication equipment, but he did not document these discussions, and the resident reported that months had passed without further contact or resolution. Overall, the report documents that grievances, including those alleging neglect, were not promptly investigated, followed up, or communicated back to residents and families.
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