Grievance Policy Posting Deficiency
Penalty
Summary
The facility failed to ensure that the posted grievance policy and procedure met federal guidelines across three nursing units and common areas. During a resident group interview, residents expressed unawareness of the grievance policy and the procedure for filing grievances anonymously. This indicates a lack of communication and visibility regarding the grievance process to the residents. During a tour of the facility, it was observed that the grievance policy and procedure were not completely posted in the main dining room, nursing unit lounge areas, and other common areas. The postings lacked the grievance officer's contact information, instructions on how to file grievances anonymously, and the expected time frame for receiving a response. The Director of Social Services confirmed these deficiencies, highlighting the facility's failure to comply with federal guidelines for grievance procedures.
Plan Of Correction
Grievance forms were placed, and official contact information postings were immediately updated at all grievance boxes on all floors upon identification by surveyor. Residents will be notified and reoriented to the grievance procedure, grievance official, grievance box accessibility, availability of forms and response times at the next scheduled resident council meeting. Residents who do not attend resident council will be notified of the grievance procedure in writing or by the activities department. An anonymous grievance box is located in the dining room. Social Services and Activities staff will be educated by the NHA/Designee on the grievance policy and procedure and federal guidelines at F585 Grievances. Audits will be completed by the NHA or designee weekly x 4 weeks, then monthly x 2 months to ensure boxes, postings, and forms are available for resident use. All results to be reviewed through QAPI for further recommendation.