Failure to Resolve Resident Grievance Timely
Penalty
Summary
Aventura at Terrace View failed to correct deficiencies related to resident grievances as outlined in 42 CFR Part 483, Subpart B Requirements for Long Term Care Facilities. The facility did not demonstrate timely and adequate efforts to resolve grievances, specifically for one resident, identified as Resident C1. The facility's policy required that grievances be addressed within five working days, but this was not adhered to in the case of Resident C1. Resident C1 was admitted to the facility with diagnoses including overactive bladder and muscle weakness. A grievance was filed on behalf of Resident C1 on October 4, 2024, by the resident's responsible party, expressing concerns about inadequate incontinence care, as the resident was soaking through multiple pairs of pants daily. However, the grievance was not resolved until December 16, 2024, 73 days later, and the resolution was noted only as "resident deceased," with no further follow-up possible. The facility failed to provide evidence that the grievance was addressed or investigated in a timely manner. At the time of the survey on January 8, 2025, there was no documentation showing that the facility had evaluated the grievance or determined if the resident and their responsible party felt the issue was resolved. Interviews with the Nursing Home Administrator and Director of Nursing confirmed the facility's failure to resolve the grievance adequately and promptly.
Plan Of Correction
- As of 12/15/24, C1 no longer resides as facility. - All grievances from 1/7/25 forward reviewed and follow-ups completed with resident and responsible party. - Grievance policy reviewed and education provided to all staff, including administrative staff. - NHA or designee will conduct QA auditing 5 days a week for 3 months. - Audit results will be presented at the monthly QAPI meeting.