Failure to Document and Track Resident Grievances per Facility Policy
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to voice grievances and to follow its own grievance policy, including proper documentation and tracking of grievances. During an observation, the Social Worker provided the grievance binder, which contained documentation only back to December 2025, despite her having been the appointed grievance coordinator since October 2024. The facility’s written grievance policy, dated 11/2/2016, states that residents have the right to voice grievances regarding care and treatment, staff behavior, and other concerns, and that the grievance official must oversee the grievance process, receive and track grievances to their conclusion, lead investigations, and issue written grievance decisions. In interviews, the Social Worker stated she had no documented grievance forms from residents regarding care from staff prior to the recent period and explained that, under the previous DON and Administrator, she had been instructed not to complete grievance forms for grievances related to staff care. Instead, she was told to verbally report such concerns directly to the previous DON and Administrator, who indicated they would handle them, and she did not document these grievances despite recognizing that resident care concerns qualified as grievances that needed to be documented. She acknowledged that this practice was not in compliance with the facility’s grievance policy and that concerns such as those involving CNA A should have been documented in accordance with that policy. The ADON confirmed that residents could report care concerns to any staff member and that quality-of-care concerns reported to her should have been documented on a grievance form, adding that everything needed to be documented in the system and grievance binder. She stated she was not aware of the previous Administrator’s and DON’s instructions to the Social Worker not to document grievances related to staff care. The current DON observed that the grievance binder appeared empty, with the earliest grievances only dating back to December 2025, and stated that the prior practice of only verbally reporting concerns to the previous DON and Administrator was not aligned with the facility’s grievance policy. She noted that without adherence to the policy and proper documentation, grievances could be lost, the facility could be unaware if grievances were unresolved, and there would be no documentation to support resolution or to reference during investigations, including those related to CNA A’s behavior.
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