Failure to Resolve Resident Grievance Timely
Penalty
Summary
The facility failed to make ongoing efforts to resolve grievances for a resident, identified as Resident 18, who was cognitively intact and required assistance from staff for care. The resident filed a grievance on December 25, 2024, regarding not receiving her gas pill and not being washed up for the day. Despite asking for assistance from a nurse aide and an LPN at 1:00 p.m., the resident was not attended to until 3:00 p.m. by two unknown nurse aides. The grievance was not assigned until January 7, 2025, and there was no documented evidence of a thorough investigation, including interviews or written statements from the staff involved. The grievance form indicated that nursing was to review medication changes with the resident, but there was no documentation of whether the grievance was confirmed or not. Additionally, there was no evidence of ongoing efforts to resolve the resident's concerns until January 28, 2025, when the Nursing Home Administrator met with the resident to discuss changes to her care. The resident was not informed of the grievance resolution until January 29, 2025, over a month after the grievance was filed. An interview with the Nursing Home Administrator confirmed the lack of documented evidence of ongoing efforts to resolve the grievance and the delay in informing the resident of the resolution. This failure to address the grievance in a timely manner and to keep the resident informed of the resolution process is a deficiency in the facility's grievance handling procedures.
Plan Of Correction
Preparation and submission of this Plan Of Correction (POC) is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. Resident #18 grievance was resolved and reviewed with the resident at the time of the survey. To identify other residents with the potential to be affected, the Social Service Department/designee will audit grievances for the month of January to ensure they were addressed and to resolve per policy. To prevent a future occurrence, the Director of Nursing/designee will educate department heads on the grievance policy. To monitor and maintain ongoing compliance, the Director of Nursing/designee will complete an audit of current grievances to ensure they are addressed and resolved timely weekly x4 and then monthly x2. Results of audits will be forwarded to facility's Quality Assurance and Process Improvement committee for review upon completion for review and recommendations.