Failure to Address Resident Council Grievances
Penalty
Summary
The facility failed to ensure that grievances raised by the resident council were fully and promptly addressed. During a resident council meeting, ten participants confirmed ongoing complaints about delayed responses to call lights, particularly during the third shift, and the lack of staff wearing name tags. Residents also expressed concerns about insufficient staffing, which affected the availability of restorative care, and issues with the facility's cable TV service. Despite these grievances being discussed in meetings, they were not logged in the grievance log or documented as addressed. The resident council meeting minutes revealed several unresolved issues, including the need for staff to wear name tags, education on diets, and the installation of a second rod in closets for wheelchair users. Additionally, residents requested Spanish language lessons due to language barriers with staff. Other concerns included the need for department heads to be identified, visitors not signing in and out, and the absence of garbage bags in restrooms. These grievances were not documented or followed up on, as required by the facility's policies. Interviews with the Activities Director (AD) and the Nursing Home Administrator (NHA) highlighted a lack of understanding and execution of the grievance process. The AD was unaware of the need to initiate grievances from council meetings, while the NHA believed that grievances were addressed promptly and documented. However, the facility's policies on resident council and grievance programs were not adhered to, as grievances were not logged, and resolutions were not communicated effectively to the residents.
Plan Of Correction
On , the Executive Director reviewed the last 3 months of resident council meeting minutes with the Resident Council President and wrote a grievance for the identified concerns. All residents have the potential to be affected. Appropriate notice and invitations were provided for a Resident Council meeting. The Resident Council meeting was held on with, Long Term Care Certified Ombudsman present and residents report satisfaction with facility response to the previously cited grievances. On , the facility Executive Director/Nursing Home Administrator educated the Activities Director on the Resident Council policy and procedures as well as the facility Grievance policy and procedures. A Resident Council concern/grievance follow up form was created and incorporated to ensure that the Executive Director and Resident Council President confirm each month that follow up to grievances brought forth in the Resident Council meeting is appropriate. Results of the Resident Council concern/grievance follow up forms will be tracked and trended and reported monthly to the Quality Assurance Performance Improvement Committee until sustained compliance achieved.