Failure to Resolve Resident Grievances Promptly
Penalty
Summary
The facility failed to make ongoing efforts to resolve grievances and provide timely follow-up with residents and/or their representatives regarding the status of grievance resolutions for three of seven residents reviewed. The facility's policy, titled "Resident Grievances and Concerns Policy," outlines that upon receipt of a grievance, the Grievance Official should take immediate action to prevent further potential violations and complete the grievance review within a reasonable time frame, not exceeding thirty days. However, interviews with residents and family members revealed that grievances were filed but not addressed, and no responses were received from the facility. Resident 107 reported filing three grievances within the last two months without receiving any response. An aide assisted her in filling out the concern forms, which were then placed in the grievance box. Similarly, Resident 15 stated that she filed a written grievance about six months ago and never received a response. Additionally, Resident 4's family member reported filing 30-40 concern forms since admission in April 2024, with only 2-3 being addressed. The family member expressed concerns about dietary issues, lack of fresh water, staff treatment, wandering residents, and other care concerns, noting that staff members would fill out paperwork but fail to follow up. The grievance log for Resident 4 showed only three grievances on file since admission, all marked as resolved, but there was no documented evidence of investigation or resolution for additional grievances. The Nursing Home Administrator confirmed the lack of documentation and was unable to provide evidence of prompt efforts to resolve grievances or keep residents and families informed of progress. This deficiency highlights the facility's failure to adhere to its grievance policy and ensure residents' rights to voice grievances without fear of reprisal and receive timely resolutions.
Plan Of Correction
Step 1 R4, R107, & R15 will be interviewed to determine if they have any unresolved grievances. Follow up will occur based on the findings of the interviews. Step 2 To identify other residents that have the potential to be affected, the DON / designee will interview residents with a BIMs of 12 or greater to determine if they have any unresolved grievances. The residents with a BIMs less than 12 will have their representative contacted to determine if they have any unresolved grievances. Follow up will occur based on the findings. Step 3 To prevent this from reoccurring, the staffing educator / designee will educate community staff on the grievance process. Step 4 To monitor and maintain compliance, the IDT team will interview 10 residents and 10 resident representatives to ensure that any grievances that they have voiced have been followed up on. The audits will be completed weekly times 4 weeks and then monthly times 3. The results of the audits will be forwarded to QAPI committee for further review and recommendations.