Failure to Address Resident Grievances
Penalty
Summary
The facility failed to adequately address and respond to grievances filed by residents and their families over a six-month period from June 2024 through November 2024. The facility's policy on Resident and Family Grievances, dated December 3, 2024, mandates that grievances be handled without discrimination or fear of reprisal, with a written decision that includes specific details such as the date received, investigation steps, findings, confirmation status, corrective actions, and the date of the decision. However, a review of grievance forms on December 17, 2024, revealed that these forms were incomplete, and residents or their representatives were not informed of the outcomes. During a group interview, two out of seven residents expressed concerns about not being notified of grievance outcomes. The Social Service Director confirmed the facility's failure to respond to grievances in a timely manner during an interview on December 18, 2024.
Plan Of Correction
Whole house audit of resident grievances to identify any outstanding issues conducted on 1/8/2025. All previous grievances have been resolved. Residents will sign completed grievance form and will be offered a copy if requested. Education on resident/family group to ensure social worker is aware of new process of resident signing off on grievance paper will be provided to the social worker by the NHA or designee on or before 2/18/2025. Audits will be conducted on grievance process by DON or designee weekly x 4 weeks and monthly x 1 month. Audit results will be reviewed through the monthly QAPI process/meeting.