Failure to Provide Anonymous Grievance Filing
Penalty
Summary
The facility failed to protect the rights of residents and their representatives to file grievances anonymously, as required by their own policy. The policy, dated 2001, stated that grievances could be submitted orally or in writing and could be filed anonymously. However, during observations, it was found that grievance forms were not available for public use, and there was no way for residents to take a grievance form anonymously to fill out and submit. The grievance forms were stored in locations that required residents to ask staff for access, which compromised anonymity. Interviews with the Social Worker (SW) #16, who was the grievance officer, revealed that the facility practice required residents to inform staff or the SW if they wished to file a grievance. The SW stated that grievances could not be addressed without knowing who made them, although she claimed to keep grievances confidential. Observations confirmed that grievance forms were kept behind nursing stations or in closed cabinets, requiring residents to request assistance to access them. Interviews with the Administrator and the Director of Nursing (DON) confirmed that there should be an option for residents and their families to file grievances anonymously, which was not being facilitated by the current practice.
Plan Of Correction
How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: No residents were affected by the deficient practice. We have promptly implemented corrective actions for all residents in the facility to enhance the grievance process. This includes: **Increased Access to Grievance Forms:** Grievance forms are now readily available in public areas, allowing both residents and family members to easily access and submit their concerns anonymously. **Placement of Grievance Forms:** The forms are strategically posted at the reception desk, in front of the activities room, and at the East Social Service office for maximum visibility. **Secure Grievance Submission:** A locked grievance box has been installed at both the East and West Nurses stations, ensuring confidentiality. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. How the facility plans to monitor its performance to make sure that solutions are sustained: To ensure that the identified deficiencies do not recur, the facility will implement the following systemic changes: **Enhanced Accessibility to Grievance Forms:** Grievance forms are now readily available in public areas, ensuring both residents and family members can easily access them. **Strategic Placement:** Grievance forms have been posted in visible locations, including the reception desk, the activities room, and the East Social Service office, to facilitate convenient access. **Secure Submission Process:** Locked grievance boxes have been installed at both the East and West Nurses stations, ensuring that grievances can be submitted confidentially. **Education of Staff:** The Social Services and Activities Departments have been reeducated on 3/7/25 and 3/19/25 on residents' rights to file grievances anonymously, reinforcing the importance of this practice in supporting resident empowerment. **Communication:** The locations of the grievance forms and locked boxes were clearly communicated during the resident council meeting, ensuring that all residents are aware of how to voice their concerns. These measures aim to create a transparent and effective grievance process that empowers residents and their families, ultimately contributing to ongoing quality improvement within the facility. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: The grievance form clipboards and locked grievance boxes are monitored Monday-Friday by the social service director throughout the week to ensure that forms remain available and that any grievances submitted are promptly received and processed. Furthermore, the facility will implement a monthly review of the grievance logs as part of its Quality Assurance and Performance Improvement (QAPI) program. This proactive approach will help to ensure that the grievance management systems are functioning effectively and efficiently. Include dates when corrective actions will be completed: 3/24/2025 What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: The grievance form clipboards and locked grievance boxes are monitored Monday-Friday by the social service director throughout the week to ensure that forms remain available and that any grievances submitted are promptly received and processed. Furthermore, the facility will implement a monthly review of the grievance logs as part of its Quality Assurance and Performance Improvement (QAPI) program. This proactive approach will help to ensure that the grievance management systems are functioning effectively and efficiently. Include dates when corrective actions will be completed: 3/24/2025