Failure to Follow Grievance Policy for Family Concerns About Hair Care and Nutrition
Penalty
Summary
The deficiency involves the facility’s failure to follow its grievance/complaint policy and to ensure that a resident’s family grievances were formally recognized, investigated, and documented. A resident with dementia, diabetes mellitus, hypertension, end stage renal disease, adult failure to thrive, and malnutrition had an established care plan addressing ADL self-care deficits, impaired cognition, nutritional problems, and a therapeutic renal diet with supplements. On one evening, the resident’s family member voiced concerns to an LVN about how CNAs were combing the resident’s hair with ponytails, bright-colored ties, ribbons, and barrettes, which the family member felt did not treat the resident with dignity and respect. The same family member also raised concerns about the food served to the resident, including a dinner meal that appeared inadequate and concerns that the resident was not receiving enough protein. Nursing documentation showed that on the date of the complaint, the LVN recorded that the family member called about how CNAs were preparing the resident’s hair and that the LVN explained she would pass the information on to CNAs and nurses. A second nursing note documented that the Dietary Manager was notified that the family had concerns regarding food. However, review of the facility’s grievance binder revealed no grievance report from January onward related to the family’s concerns about the resident’s hair or food. The facility’s grievance policy required that grievances from residents or family members be filed, investigated by a designated grievance officer, and responded to in writing, but the grievance officer line on the policy was left blank, and there was no evidence that the concerns were processed through this system. Interviews further demonstrated that the concerns were not handled through the formal grievance process. The DON stated he had not been informed about the hair-combing concern and was not familiar with the facility’s grievance/concern procedures; he also acknowledged not documenting the family’s concerns about the resident’s diet in the clinical record. The Dietary Manager reported that she was not present when the family voiced concerns about the food, that she attempted to call the family twice, but she did not complete a grievance/concern form or document her follow-up in the resident’s record. The Social Worker, who was responsible for completing grievance/concern forms, stated that no one had reported the family’s concerns about the resident’s hair or food to her. As a result, the family’s grievances regarding the resident’s hair styling, the adequacy and type of food served, the uneaten dialysis sack lunches, the missing blanket, and care plan meeting participation were not entered into the grievance system, not investigated per policy, and not responded to in writing as required. Additional observations and interviews highlighted the underlying events but did not change the fact that no formal grievance process was initiated. Staff reported that the resident did not eat her packed dialysis lunches due to nausea and that the lunches were returned untouched, while the family member believed staff were not checking the bag upon the resident’s return. The resident herself stated she liked the way staff had previously combed her hair with ponytails and accessories but that this stopped after her family member objected; she appeared sad and said she would do whatever her family member wanted. The family member also reported that a long‑owned blanket had gone missing and that staff only replaced it with another blanket and asked if it had been labeled, without escalating the issue to administration or the Social Worker. The family member further stated that she had not been invited to care plan meetings after staff changes and that a scheduled care plan conference had been canceled and not rescheduled. None of these concerns were captured in the grievance binder or processed according to the written grievance/complaint policy, constituting the cited deficiency.
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