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F0585
D

Failure to Resolve and Communicate Grievance Outcomes

Warminster, Pennsylvania Survey Completed on 03-20-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure prompt resolution of grievances and effective communication of grievance resolutions for several residents. During a Resident Council meeting, eleven residents expressed concerns that the facility did not provide them with information regarding the resolution of their grievances after investigations were completed. This indicates a lack of communication and follow-through in addressing residents' grievances as per the facility's policy. One specific case involved a resident who was admitted with diagnoses including heart failure, cellulitis, and type 2 diabetes. This resident filed a grievance regarding missing clothing that was sent to the laundry and not returned. Despite the grievance being filed, the issue remained unresolved, and the resident was left using hospital gowns due to the lack of personal clothing. The grievance form indicated that the social worker met with the resident to select new clothing from a catalog, but the items were not ordered, highlighting a failure in the grievance resolution process. The facility's grievance policy, which requires grievances to be resolved within seven days, was not adhered to in this case. The social worker confirmed that the grievance was filed, but no action was taken to order the clothing, leaving the resident without a resolution. This situation exemplifies the facility's failure to make prompt efforts to resolve grievances and communicate effectively with residents about the outcomes of their complaints.

Plan Of Correction

1. Social Services met with R4, R6, R13, R35, R49, R62, R70, R92, R93, R96, R129 to discuss any grievances they have had within that they did not have the outcome of. R30 grievance and that it was resolved and that she was given clothing to wear. Outcome. 2. Reviewed Grievances dated March 1 to current and met with residents/person who initiated the grievance to ensure they are aware of outcome of grievance. 3. Education provided to Social Services and All Department Heads that All Grievance outcomes will be reviewed with the resident/person that initiated the grievance and will have sign off that it was reviewed. 4. Random audits by the Administrator/designee to ensure that Grievance outcomes are being reviewed and signed off on with the resident/person initiated once a week for one month, twice a week for one month, and once a month for one month. The findings of the audits will be brought to the Quality monthly Quality Assurance Improvement Committee (QAPI) meeting monthly for a period of three months. Any revisions to the audit plan will be reviewed and implemented with coordination of the interdisciplinary team at QAPI Committee meeting.

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