Failure to Follow Grievance Process for Resident Complaint
Penalty
Summary
The facility failed to ensure staff were knowledgeable of and followed their grievance process for a resident who filed a concern about being yelled at by a CNA. The resident, who was cognitively impaired and dependent on staff for personal hygiene, reported that the CNA yelled at her for needing to be changed again. The grievance was documented but not properly investigated or followed up with the resident, and it was not reported to the State agency as required. The Social Services Director, who was responsible for overseeing grievances, and the Administrator were not aware of the grievance until it was brought to their attention during the survey. The grievance was not discussed in detail during morning meetings, and the Administrator confirmed that it was not investigated as required. The facility's grievance policy, which mandates prompt efforts to resolve complaints and inform residents of progress, was not adhered to in this case.
Plan Of Correction
This plan of correction is submitted as required under Federal and State regulations and statutes applicable to long term care providers. This plan of correction does not constitute an admission of liability on the part of the facility, and such liability is hereby specifically denied. The submission of this plan does not constitute agreement by the facility that the surveyors findings or conclusions are accurate, that the findings constitute a deficiency, or that the scope or severity regarding any of these deficiencies cited are correctly. 1) On , Resident #7 reported grievance was submitted to AIRS system by NHA. (2) A comprehensive review of all grievances for the months of and was conducted by Regional Vice President of Operations, Executive Director and Social Services Director to ensure adherence to facility policy. No new issues found. (3) 1. Education provided by RVPO to SSD and ED on grievance and reporting process. 2. Education provided to all staff on the grievance and reporting process, postings and placement of grievance forms. 3. All grievances are reviewed by ED, SSD and DON daily; supervisor calls and reviews grievances with ED, SSD, DON or designee on weekends. 4. Grievance policy reviewed by Executive Director in resident council meeting on. 5. A quality review is conducted weekly by ED/DON or SSD on grievances and reportable incidents. (4) A quality review will be completed by the Executive Director/designee of grievances and reportable incidents, to ensure the policy/process is adhered to, 5 times a week for 4 weeks, and then weekly for 2 months. The findings of these quality reviews will be reported to the Quality Assurance/Performance Improvement Committee monthly until committee determines substantial compliance has been met.