Failure to Investigate and Resolve Resident Grievances
Penalty
Summary
The facility failed to ensure that resident grievances were investigated and resolved for three residents. Resident R12 reported a grievance about receiving cold breakfast meals, but there was no documentation of any investigation or resolution provided by the facility. This indicates a lack of follow-through on the part of the grievance official or the designated department responsible for addressing such concerns. Resident R15 filed a grievance upon admission, reporting that her room was not clean and contained someone else's belongings. Additionally, she did not receive requested food items such as soup and tea. The facility did not document any investigation or resolution for these grievances, showing a failure to address the resident's immediate concerns and uphold the grievance policy. Resident R14's daughter submitted a grievance regarding multiple issues, including cold meals and missing food items. She detailed specific instances where her father received cold food and incomplete meals, which were not addressed by the facility. The lack of investigation and resolution for these grievances highlights a systemic issue in the facility's grievance handling process, as evidenced by the absence of documented actions or solutions for the residents' reported concerns.
Plan Of Correction
The facility cannot go back retroactively to correct this issue. The NHA/designee conducted an audit of the last 2 weeks of grievances to ensure grievances are investigated and resolved. The Interdisciplinary Team was educated on the grievance policy by the Regional Nurse. The NHA/designee will audit grievances to ensure grievances are investigated and resolved. Audits will be done weekly x 4 weeks then monthly x 2 months. Results of these audits will be submitted to the Quality Assurance Committee to determine if further action is needed.