Failure to Address Grievances and Long Call Bell Wait Times
Penalty
Summary
The facility failed to ensure prompt resolution of grievances for all residents reviewed, including one specific resident who filed a formal grievance. Nine residents expressed during a group meeting that they were unaware of the grievance official or the process to file a grievance. The facility's policy required that residents be provided with the means to file grievances, but there was no posted information about the grievance officer or accessible grievance forms observed during the survey. Long call bell wait times were a recurrent issue reported in monthly resident council meetings, and these concerns were documented in meeting notes from July to November 2024. Resident #446 had filed a formal grievance regarding the long call bell wait times, which was not promptly addressed. Observations during the survey revealed significant delays in call bell responses, with instances of call bells going unanswered for extended periods, ranging from 28 to 45 minutes. Staff members, including a Registered Nurse Unit Manager and other unidentified staff, were observed ignoring active call bells. Interviews with the Director of Activities, Director of Social Services, and Director of Nursing confirmed that long call bell wait times were a frequent grievance. The Director of Social Services, who served as the grievance officer, acknowledged the issue and stated that investigations and staff education were conducted, but the problem persisted. The Director of Nursing noted that despite in-services and changes in staff assignments, a solution to the long call bell wait times had not been found, indicating a systemic issue within the facility's operations.
Plan Of Correction
Plan of Correction: Approved March 3, 2025 The following corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: - Public post throughout the facility the Official Grievance Officer, their contact information, and where to file an official grievance. - Educate nursing staff on call bell timeliness. - Review with resident council who the grievance officer is and how to contact them. - Notify Resident #446 of grievance outcome and resolution and complainant satisfaction and reassessment if needed. The facility will identify other residents having the potential to be affected by the same deficient practice and the following corrective action will be taken: - Audit Call (NAME) wait times, educate, monitor and enforce timeliness. - Audit units for posting on Grievance Officer name, contact information and process/availability – ensure posting of information is available throughout the facility. The following measures will be put in place and/or systemic changes will be made to ensure that the deficient practice does not recur: - Education on the Grievance Procedure/Officer to resident council. - Education on Call-Bell Timeliness to LPN/CNA staff. The corrective action(s) will be monitored to ensure the deficient practice will not recur: - Post information on Grievance Officer, contact information and process/availability to file a grievance. - Audit Call (NAME) Timeliness x5 a week per unit for 3 continuous months for 100% compliance. The date for correction and the title of the person responsible for correction of each deficiency: - Date of Correction: 3/5/2025 - Person Responsible: Nurse Manager.