Failure to Complete and Communicate Required Written Grievance Decision
Penalty
Summary
The facility failed to honor a resident's right to voice grievances without reprisal by not completing and providing a written grievance decision with all required components. Resident #67, who was cognitively intact, had a grievance form completed on 3/5/26 by the Social Worker (SW) regarding concerns about night shift staff not being attentive, not providing incontinence care during the night, and not checking on her every two hours. The grievance form only documented that education would be provided by the Staff Development Coordinator and did not include how the grievance was investigated, a summary of pertinent findings or conclusions, a statement as to whether the grievance was confirmed or not confirmed, or the date a written grievance decision was provided to the resident. During an interview, Resident #67 reported she continued to experience issues with incontinence care not being provided routinely on night shift and stated she had raised these concerns during a care plan meeting. She indicated she did not know whether her concern had been addressed and had not been verbally informed of any grievance decision or received a written grievance decision. The SW reported she was responsible for managing grievances and described a process in which she completed the grievance form, assigned it to the appropriate department, and verbally followed up with that department, but she did not document the investigation, findings, resolution, or dates on the grievance form. She also stated she did not follow up with the individual who filed the grievance to inform them of the investigation, findings, or resolution and did not provide written notification of the grievance outcome, indicating she was unaware these steps were required. The Administrator stated that grievances should include documentation of investigation, findings, corrective actions, resolution, and notification to the complainant, and was not aware that the SW was not completing these steps.
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