Grievance Procedure and Form Accessibility Deficiency
Penalty
Summary
The facility was found to be non-compliant with the requirements for handling resident grievances. Specifically, the facility failed to ensure that anonymous grievance forms were readily accessible for resident use and did not post the grievance procedure in prominent areas on two of its nursing units, Two East and Three East. This was determined through a review of the facility's policy, resident interviews, observations of resident areas, and staff interviews. A resident, who had been at the facility for two and a half years, reported that there were no grievance forms available, suggesting that employees were aware that residents could not easily file complaints. Observations during tours of the Two East nursing unit and resident solarium/common area confirmed the absence of grievance forms and the lack of a posted grievance policy. Additionally, the Three East nursing unit had a grievance procedure posted, but it was incomplete, missing the name of the compliance officer and a mailing address. Interviews with staff, including an LPN Supervisor and an RN Supervisor, confirmed the facility's failure to make anonymous grievance forms accessible and to post the grievance procedure as required. These deficiencies were noted as violations of resident rights and management regulations, as outlined in the facility's grievance policy and state codes.
Plan Of Correction
1. Grievance forms and policy were placed in resident common areas on 2 east and 3 east. 2. A house audit was completed of all other resident units to ensure grievances and grievance policy were present and easily accessible to residents. No further issues identified. 3. Director of nursing will in-service social workers on ensuring grievance policy and grievance forms are readily accessible to residents on all units. 4. Director of social services or designee will audit 3 units weekly for 2 weeks, then 2 units weekly for 2 weeks, then 3 units monthly for 2 months to ensure grievance forms and policy are accessible to residents. Audit findings will be shared with QAPI committee.