Failure to Document and Resolve Grievance for Broken Eyeglasses: A resident admitted for short-term rehab with cellulitis and a BIMS score indicating cognitive intactness had eyeglasses lost in the laundry and later found damaged. The family repeatedly contacted the AD and NHA about reimbursement for replacement glasses, but the concern was not entered on the grievance log, was not clearly investigated or tracked, and remained unresolved despite multiple emails and staff awareness.
A resident with intact cognition and mental health diagnoses reported that staff cleaned and organized her room without permission while she was out, after which she discovered missing personal items including blankets, a doll, a stuffed rabbit, and clothing. She stated she reported this concern to multiple staff members without resolution and felt the NHA/DON did not care. The NHA/DON acknowledged knowing about the complaint and discussing it with the ombudsman and guardian but did not complete a grievance form, did not document the concern in the EMR, and could not verify any follow-up with the resident, contrary to the facility’s written grievance policy requiring documentation and a written decision.
A resident who was totally dependent for ADLs and had progressive MS, neuromuscular bladder dysfunction, and moderate cognitive impairment reported lying in a soiled brief for about four hours after requesting help, ultimately calling 911 twice when staff did not respond and the brief was not changed. The resident also described chronic issues with night-shift call lights going unanswered for over two hours, staff sitting in the hall on their phones, missed bed baths, rude agency CNAs, and staff cursing at patients. Only one grievance form was found documenting these concerns, which noted that staff education would occur, but there was no evidence the education was completed. The DON gave inconsistent statements about awareness of the 911 incident and did not respond to follow-up from external authorities, and the facility did not follow its own grievance policy requiring thorough investigation and resolution of alleged neglect.
A facility failed to provide an effective grievance process when residents reported that grievance forms were not readily accessible in common areas and that they did not know they could complete them themselves or ask for help. Residents also described ongoing unresolved concerns, including long call light wait times, staff turning off call lights without providing care, missing clothing, and other care and service issues. Record review showed these concerns from Resident Council meetings were not identified or documented as grievances, and interviews showed inconsistent staff knowledge of where grievance forms were kept.
A resident with chronic inflammatory demyelinating polyneuritis and bradycardia, who was bedbound but cognitively intact, discovered through her medical record that a restorative nursing program for ankle ROM and bed mobility had been ordered but was rarely provided. She filed a written grievance describing that the restorative therapy, important to her physical health, had not been started as ordered and identified multiple staff who were aware of the issue. The facility could not locate its copy of the grievance, did not have it in recent grievance files, and did not maintain a grievance log, despite a policy requiring timely investigation and tracking of concerns such as missing therapy services. Task logs confirmed that the ordered restorative interventions were documented only a few times over a month, with many entries marked "Not Applicable" or "Resident Refused," and the resident reported receiving the service only a handful of times, with no documented follow-up to her grievance.
The facility failed to provide a way for visitors, staff, and residents to submit concerns and grievances anonymously. Observation showed no grievance form available outside the nurse's station and no drop box or other location for anonymous submission. The DSS stated grievances were not completed unless a resident asked for one, while the DON said the policy allowed anonymous grievances but there was no specific location for filing them.
Resident Council members were not informed of their right to file grievances or where to obtain grievance forms. During a Resident Council meeting, all participants reported ongoing concerns about food, noise, late meds, and call light response times, and none knew filing a grievance was an option. Minutes from prior Resident Council meetings did not show review of resident rights or the grievance policy, and the Activity Director stated she thought she had mentioned it in earlier meetings, but no documentation was provided.
A resident with intact cognition and multiple medical and psychiatric diagnoses repeatedly voiced concerns, through the State Ombudsman and directly, about staff being rude, turning off call lights without returning, delaying assistance, discouraging toileting by instructing use of briefs, limiting therapy focus on transfers, and prohibiting use of a personal glucometer. The Ombudsman relayed these concerns to the NHA, and the resident reported that issues persisted and had not been resolved to her satisfaction. Staff acknowledged some complaints but did not complete grievance or concern forms, and one nurse characterized the complaints as normal behavior. The Ombudsman reported the facility did not offer to complete or provide complaint forms. The NHA confirmed that no concern forms were completed for this resident, despite a written Care Program policy requiring that all oral and written concerns be documented on a Resident, Family, Employee and Visitor Assistance Form, investigated via IDT, logged for QA tracking, and followed up to ensure satisfaction. This failure to follow the grievance policy and formally document, investigate, and evaluate the resident’s concerns resulted in the cited deficiency.
Failure to inform residents of the grievance process and ongoing call light delays. During a confidential Resident Council meeting, 8 residents reported repeated slow call light response times, including waits of more than 1 hour on the night shift, and said staff responses were dismissive and made them feel like a bother. The residents stated the issue had been discussed for months without improvement, and none of the 8 residents knew where to find a grievance form or how to complete the grievance process.
Failure to Timely Resolve Repeated Resident Grievances: A group of residents repeatedly voiced concerns about blocked hallways, staff using phones or earbuds during care, rude behavior, delayed call light response, staff leaving to smoke, and inconsistent water delivery. Resident Council minutes showed the same issues recurring over multiple months, and the residents reported that complaints were brought up again and again without resolution. Concern forms were often incomplete, and interviews with the NHA and DON confirmed that the concerns were discussed but not consistently resolved.
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