Failure to Address and Document Resident Concerns
Penalty
Summary
During a Recertification Survey conducted from January 6 to January 14, 2025, it was found that the facility failed to adequately address and document concerns raised by residents during Resident Council meetings. Six residents reported various issues, including the use of inappropriate silverware, lack of linens, restrictions on going outside, undignified treatment by staff, and delayed response to call lights. These concerns were voiced during a special Resident Council meeting on January 7, 2025, and had been recurring over the previous six months. However, the facility did not provide any follow-up, resolution, or rationale for the lack of resolution to these concerns in the meeting minutes. Interviews with the Director of Recreation and the Administrator revealed that while there was a protocol for addressing resident concerns, it was not being followed. The Director of Recreation admitted that complaints were addressed but not documented, and there was no manual or electronic record of resident concerns or follow-ups. The Administrator confirmed that directors present at the meetings should document concerns and follow-ups, but acknowledged that the follow-up process was not documented. This lack of documentation and follow-up on resident concerns constitutes a deficiency in honoring residents' rights to organize and participate in resident/family groups and have their concerns addressed.
Plan Of Correction
Plan of Correction: Approved February 7, 2025 1. The social worker will meet with each resident to document each of their concerns on a grievance form. Each concern will be investigated and a resolution put in place to address the individual concern. The social worker will then address each resident with the findings and resolution to their concerns, as applicable. 2. All residents have the potential to be affected. The facility will review 12 months of Resident Council minutes to ensure that each concern brought up at the meeting was properly reviewed and addressed. 3. The recreation staff, the social worker, and the administrator were educated on the requirement to ensure that every concern or grievance brought by a resident during Resident Council Meeting must be documented and followed up with a response and provide a rationale for the response. Every resident council will be audited 2 weeks after the meeting to ensure that every concern is responded to as required. 4. The facility will audit the monthly resident council minutes for 4 months. Results of the audits will be brought to the QAPI meeting for review. The Director of Activities is the responsible party.