Failure to Provide Required Written Grievance Summaries to Resident’s Representative
Penalty
Summary
The deficiency involves the facility’s failure to provide written grievance summaries to a resident’s responsible party (RP) as required by facility policy and resident rights regulations. The facility’s grievance policy dated 08/2023 states that the Administrator is responsible for overseeing the grievance process, including receiving and tracking grievances, leading investigations, reaching conclusions, taking appropriate actions, and communicating the conclusion and corrective actions to the resident or the person acting on their behalf. The policy further states that the resident or their representative has the right to obtain a copy of the written conclusion. Despite this, multiple grievance forms related to one resident contained blank sections where written decisions, notification methods, summaries of findings, corrective actions, and signatures should have been documented. The resident involved was admitted and later readmitted to the facility, and an MDS assessment indicated the resident was severely cognitively impaired. The facility’s grievance log from January 2025 through March 2026 showed four grievances submitted by the resident’s RP. These grievances concerned ADL care with the resident being found wet and soiled, missing washable pads and a listening ear microphone, concerns about the resident’s hair appearance, and discoloration on the resident’s hands following a lab draw. For each of these grievances, the corresponding grievance forms lacked completion of key sections, including the date the written decision was issued, the method used to notify the resident or RP, the delivery method of the conclusion, whether the conclusion was accepted or declined, the summary of pertinent findings and conclusions, corrective actions taken, and the RP’s signature. Interviews confirmed that the RP did not receive written grievance summaries or follow-up notifications for any of the grievances filed. The RP reported submitting multiple verbal grievances to administrative staff, including the Administrator, and stated she was not asked if she wanted a written grievance summary and did not receive written or verbal updates or follow-up interviews regarding her concerns. The Administrator acknowledged that the RP did not receive written grievance summaries and stated she was not fully aware that written summaries were required for complainants or those filing grievances on the resident’s behalf, even when issues were resolved verbally. The Director of Clinical Services also confirmed that the RP did not receive verbal or written grievance summaries or follow-up notifications for the grievances she filed.
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