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F0585
D

Failure to Document and Resolve Resident Grievance

Philadelphia, Pennsylvania Survey Completed on 01-31-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to demonstrate evidence that a grievance filed by a resident was promptly documented and resolved. A resident reported a serious incident where another resident entered her room and engaged in inappropriate behavior. The resident, feeling harassed, reported the incident to the staff and completed a grievance form. However, the facility did not follow up with the resident regarding the grievance, and there was no evidence of the grievance being documented or resolved. The facility's policy requires that grievances be documented and resolved promptly, with the resident being informed of the findings and actions taken. Despite this policy, the facility was unable to locate the grievance form submitted by the resident, and the content of the grievance was unknown to the facility staff. Interviews with the Director of Nursing and the Social Worker confirmed that the grievance was filed, but the facility failed to track or address it appropriately. This deficiency highlights a failure in the facility's grievance process, as the resident did not receive any follow-up or resolution to her complaint. The lack of documentation and communication regarding the grievance indicates a significant oversight in handling resident concerns, particularly those involving serious allegations.

Plan Of Correction

This plan of correction is submitted to comply with federal regulations. This plan is not an admission of guilt, or wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. R110 A grievance form was completed with the resident and resolution reviewed with her. The last 2 weeks of grievances were reviewed to ensure prompt documentation of the grievance and timely follow-up with the resident and or resident representative. The Director of Social Service/designee educated staff on the grievance process. The Director of Social Service/designee will audit grievances submitted to ensure timely documentation of the grievance as well as prompt follow-up and communication to the resident and or resident representative. 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.

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