Failure to Provide Anonymous Grievance Options
Penalty
Summary
Kadima Rehabilitation and Nursing at Washington was found to be non-compliant with the requirements of 42 CFR Part 483, Subpart B, specifically regarding the handling of grievances. The facility failed to provide residents and visitors with the necessary means to file grievances anonymously. During the survey, it was observed that the only grievance box available was located in the front lobby, directly in front of the Nursing Home Administrator's office and within sight of the receptionist, which compromised the anonymity of the grievance process. Additionally, there were no grievance forms or boxes available on the nursing units, further limiting the residents' ability to voice concerns without fear of reprisal. Interviews with the Resident Group and the Nursing Home Administrator confirmed these findings. The Resident Group expressed that they could not file anonymous grievances due to the location of the grievance box. The Nursing Home Administrator acknowledged the lack of grievance boxes and forms on the nursing units and the absence of an opportunity for residents and visitors to file grievances anonymously. This deficiency indicates a failure to adhere to the facility's grievance policy, which is intended to support each resident's right to voice grievances without discrimination or fear.
Plan Of Correction
1. The facility will provide the opportunity for residents and visitors to file an anonymous grievance. 2. The Regional Clinical Consultant or Designee will re-educate the Nursing Home Administrator and the Social Services Director on federal regulation 0585, detailing placing grievance boxes in an area where residents and visitors can file a grievance anonymously. 3. New grievances boxes were placed in designated areas of the facility that will give residents an area to file a grievance anonymously. 4. Social Services Director or designee will educate Residents on the whereabouts of the placement of the new grievance boxes. 5. The New Grievance procedure will be forwarded to the monthly Quality Assurance and Performance Improvement Committee for review. 6. SS Director/designee will audit/monitor (using audit grid) grievance box daily for 4 weeks and manager on duty will monitor/audit daily (using audit grid) on weekends for 4 weeks. 7. Discussion/questions/concerns will be discussed at resident council. 8. The results of the audits will be forwarded to the monthly quality assurance and performance improvement committee for review and frequency of audits.