Failure to Address Resident Council Concerns
Penalty
Summary
The facility failed to ensure that residents could effectively voice their concerns during Resident Council meetings and that these concerns were documented and addressed in a timely manner. The facility's policy stated that the Life Enrichment Director or designee may attend the Resident Council Meeting to act as a liaison between the group and the facility if requested by the Council. However, the policy was not effectively implemented, as evidenced by the lack of documentation of resident concerns and follow-up actions in the meeting minutes from October, November, and December 2024. During a Resident Council meeting on January 7, 2025, seven residents expressed that their concerns were not being followed up by each department, and they never received feedback or saw resolutions to their issues. These concerns included call bell response times, snack availability, food quality, linen and care supplies availability, and housekeeping frequency. Despite these issues being raised, the Activity Director and Social Services Director were unaware of any concerns other than dietary issues, indicating a breakdown in communication and documentation. The review of the Resident Council meeting notes from the previous months revealed a lack of evidence of resident participation and facility responses to concerns. This deficiency highlights the facility's failure to adhere to its policy and ensure that resident concerns are properly documented, communicated, and addressed, leading to unresolved issues and dissatisfaction among the residents.
Plan Of Correction
a. Emergency Resident Council meeting held on January 21st to address all concerns. b. Nursing Home Administrator/designee educated Activity Director on resident council process and concern forms to be completed with each concern. c. Resident Council Concern form template updated and given to Activity Director to use with resident council concerns. d. Nursing Home Administrator/designee will meet with Resident Council president within 3 days of resident council meeting monthly (starting Jan 2025) times 3 months to verify completion of new concern forms are completed from the meeting and to discuss resolutions. Concerns will be reviewed in the old business of the next meeting. e. Findings will be summarized and brought to the quality assurance and performance improvement committee and reviewed for any further monitoring and changes needed.