Failure to Follow Grievance Process for Resident Complaint
Penalty
Summary
The facility failed to ensure that staff were knowledgeable of and followed their grievance process for a resident who had filed a complaint. The resident, who was dependent on staff for toileting hygiene and required substantial assistance for personal hygiene, reported being yelled at by a CNA after needing to be changed for the second time. The grievance was documented in the Resident Grievance Log, but the investigation findings section was left blank, and there was no follow-up or report submitted to the State agency. The Social Services Director, who was responsible for overseeing grievances, stated that grievances were discussed daily during morning meetings, but the Administrator confirmed that the specific grievance was not brought to her attention. The grievance form was handed to the Social Services Director by the Unit Manager, but it was not read or investigated as required. The facility's policy intended to support residents' rights to voice complaints and resolve them promptly, but in this case, the grievance process was not properly followed, and the grievance was not addressed or reported as necessary.
Plan Of Correction
Grievance was submitted to AIRS system by NHA. A comprehensive review of all grievances for the months of [insert months] was conducted by the Regional Vice President of Operations, Executive Director, and Social Services Director to ensure adherence to facility policy. No new issues found. 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 [insert date]. 5. A quality review is conducted weekly by ED/DON or SSD on grievances and reportable incidents. 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 the committee determines substantial compliance has been met.