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F0585
F

Lack of Grievance Policy and Awareness in Facility

Williamsville, New York Survey Completed on 12-06-2024

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that residents were informed about the grievance process and did not have an established grievance policy to ensure the prompt resolution of grievances regarding residents' rights. During a Resident Council meeting, all seven attendees expressed that they were unaware of how to file a grievance or who the Grievance Officer was. The residents also mentioned that the facility did not consistently respond to their concerns, which included staffing and customer service issues. Interviews with staff revealed a lack of awareness about the grievance process, with the Activities Department Director and the Director of Nursing both indicating they were unsure of the grievance policy or the location of grievance forms. Further investigation revealed that the Social Worker, who was responsible for handling grievances, had recently terminated their employment, leaving the facility without a designated Grievance Officer. The Administrator admitted that grievance forms were not readily available at the reception desk and that grievances were not being reviewed or followed up on as required. The grievance binder provided by the Administrator contained forms without department head follow-up or signatures, indicating a failure in the grievance process. The Director of Nursing confirmed that the facility did not have a grievance policy and procedure in place.

Plan Of Correction

Plan of Correction: Approved January 6, 2025 1. Social Worker met with resident 17, 34, 36, 61, 70, 82, and 96 and a copy of the updated policy and procedure was provided to explain the grievance process. Social Worker also explained to residents that the Social Worker is the grievance coordinator. All residents were provided a copy of the grievance policy and procedure with the Grievance Coordinator's name by the Social Worker. A resident council meeting was held with the Social Worker to review the process. Grievance posters and Ombudsman posters are posted on all floors, the front desk, and the chapel. The Ombudsman will be provided the resident council schedule to allow them the ability to participate. Resident rights will be reviewed at the monthly resident council meeting. 2. All residents are at risk for deficient practice of not having a process in place for residents to voice concerns. 3. Administrator created a new policy and procedure for grievances, including who is the grievance coordinator. 4. All residents were given a copy of the new grievance procedure, including who is the grievance coordinator. A family meeting was held on (MONTH) 15, 2025, to discuss the new policy and procedure on grievances. All staff were educated by the RN Educator on the new grievance policy and with all new general orientation for all new hires. 5. Social Worker was educated by the Administrator regarding the new policy and procedure. 6. All grievances will be reviewed monthly at QAPI for trends. Any deficient findings will be corrected. Person Responsible: Social Worker

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