Failure to Document and Process Resident Grievances: A resident with a stage 3 sacral pressure ulcer, quadriplegia, and neurogenic bladder repeatedly voiced concerns about delayed turning, wound vac issues, catheter care, missed transport, and fluids. Staff said concerns were often passed along verbally to the unit clerk, nurse leadership, or DON, but only two grievances were documented, and other complaints noted in progress notes were not consistently entered into the grievance log or handled through the facility’s grievance process.
Failure to Investigate Resident Grievance: A resident with a BIMS of 13 and significant ADL needs had grievances raised by her POA about an LPN’s unprofessional and undignified comments, along with delayed follow-up on lab orders. The DON and NHA acknowledged the concerns but did not document a formal grievance investigation, did not follow up with the resident, and did not track the complaint in the grievance log.
Failure to Document and Respond to Resident and Family Grievances: The facility did not consistently document or respond to grievances raised in resident council meetings or by a resident’s family member. Council concerns included cold food, missing place settings, canceled outings, RFMS access, activities, and meal service issues, while a family member reported unresolved concerns about transportation, edema, linens, and bathing/hygiene. Staff interviews showed concerns were not fully recorded, some were not entered on grievance forms, and feedback was not provided.
Failure to process a resident grievance for missing personal property. A resident with intact cognition reported missing blankets, including an electric blanket, and a CPAP machine, but staff did not file a grievance when the issue was first raised. Multiple staff members knew about the complaint, yet the SSD had no grievance on file and the NHA later acknowledged the grievance should have been initiated when the concern was first reported.
Failure to address a roommate grievance in a timely manner: two residents were reported to be cursing at each other and not wanting to remain roommates, and both were agreeable to a room change. Staff said the issue was reported to the SSD and discussed in a care plan meeting, but no grievance was filed for the situation. One resident had moderate cognitive impairment (BIMS 11) and the other had intact cognition (BIMS 15).
A resident’s grievance about the heater and his roommate was not documented on the grievance log, and the DON confirmed she received a 6-page grievance but had not specifically discussed it with the resident or kept him apprised of progress toward resolution. The resident reported he had spoken with the Social Services Director but had not heard back and felt there was no follow-through.
Failure to Document and Investigate Resident Grievances: The facility did not consistently follow its grievance process for two residents. One resident reported missing clothing from laundry on more than one occasion and said staff told him they would notify the SW and management, but he received no further information. Another resident reported a missing wheelchair charger and said she was told the facility would not pay for it. The grievance logbook did not contain either concern, and the DOSS stated she had not written a grievance for the issue.
The facility failed to document and act on grievances raised during resident council and food committee meetings. A cognitively intact resident reported that concerns voiced in council meetings were recorded but never resolved, leading to the same issues being repeated. Meeting minutes showed multiple complaints about housekeeping not cleaning rooms daily, poor customer service, staff using personal cell phones and headphones, maintenance problems without follow-through, and housekeeping moving personal items and using ill-fitting sheets. Food committee minutes documented concerns about tray accuracy, missing condiments, lack of nighttime snacks, overcooked food, dislike of canned fruit, overly strong juice, cold plates, and hard-to-chew canned fruit. None of these concerns appeared on the grievance logs, despite a facility policy requiring staff to initiate grievance forms, log complaints, and complete follow-up, and the NHA acknowledged ongoing challenges and lack of follow-through with grievances from these meetings.
A resident and the resident’s representative voiced concerns during an IDT care plan meeting and through negative kiosk feedback about nursing care, cleanliness, and customer service, but the facility did not properly log or process these concerns as a grievance. The SSD, who oversees grievances, could not identify the specific concerns raised during the care plan meeting, and the November grievance log contained no entry for those issues. A grievance later produced from kiosk feedback lacked detail about the complaint, did not document an investigation, and showed only that a room change would be offered, with resolution communicated to the resident but not the representative. Interviews with an LPN/unit manager indicated the representative had concerns about food allergies but no clear documentation of other issues, and review of the facility’s grievance policy showed requirements for investigation and communication that were not met in this case.
Failure to follow up on a resident grievance: A resident’s sister reported missing clothing items and was told a grievance would be completed, but she did not receive a resolution after several weeks. Social Svcs and the DSW were unaware of the grievance, grievance logs showed no entry for the resident, and the grievance form could not be located. The facility’s policy required investigation and notification within set timeframes.
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