Failure to Address Resident Council Concerns
Penalty
Summary
The facility failed to ensure that the views, grievances, or recommendations voiced by residents during Resident Council meetings were considered, acted upon, and responded to with a rationale. During a recertification survey, 10 anonymous residents reported that they did not receive responses to topics or concerns addressed in prior meetings. The facility's policy stated that the Resident Council would serve as a liaison between residents and facility administration, addressing concerns or complaints regarding facility operations, policies, and resident experiences. However, there was no documented evidence that residents' voiced concerns were investigated, and rationales or responses were provided to the residents. The Resident Council meeting minutes from August to December 2024 documented recurring issues such as call bells not being answered timely, medications not being available, noise levels during certain shifts, and staff using offensive language. Despite these concerns being raised repeatedly, there was a lack of documented staff responses or actions taken to address them. The Recreation Leader and Activities Director both noted that the issues were not being resolved, and the residents expressed frustration that their concerns were not being addressed, leading to a perception that attending the meetings was futile. Interviews with facility staff revealed a lack of structured follow-up on the residents' concerns. The Recreation Leader stated that they documented issues and delivered them to each department, but they were unsure why the same concerns persisted without resolution. The Activities Director, who started in November, noticed the lack of structure in the meeting minutes and recurring unresolved issues. The Administrator acknowledged seeing repeated concerns in the minutes and attributed the lack of clear follow-up to inadequate documentation, which made it appear as though the residents' concerns were not being addressed.
Plan Of Correction
Plan of Correction: Approved February 17, 2025 What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: A memo addressing cell phone use, playing music, wearing ear buds and inappropriate language will be sent to all staff directly through the employee payroll system. All old business noted on the latest resident council minutes will be addressed and responded to accordingly. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: A survey will be conducted to all residents and/or responsible parties regarding concerns, potential grievances or complaints. Each topic will be addressed and brought to the appropriate department head to respond. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur: Education was completed to all Department head level staff for addressing and responding to resident council concerns. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice: The Director of Therapeutic Recreation will report compliance at QAPI monthly for 6 months and quarterly thereafter. The date for correction and the title of the person responsible for correction of each deficiency: Director of Therapeutic Recreation.