Failure to Address Resident Council Concerns on Call Light Wait Times
Penalty
Summary
The facility failed to address and resolve concerns raised by the resident council regarding lengthy call light wait times. Interviews with staff, including a Certified Nurse Aide (CNA) and an Activities Assistant (AA), confirmed that residents had complained about the delays in response to call lights. The Resident Council Minutes from multiple meetings over several months documented ongoing issues with call light response times, including reports of aides turning off call lights without addressing resident issues and taking an extended time to return. The Nursing Home Administrator (NHA) acknowledged that while the activity director shared the resident council meeting minutes with the management team, a formal concern or grievance form was not completed for issues raised by the resident council as a whole. Instead, only resident-specific concerns were documented. This lack of formal documentation and tracking of resident council concerns contributed to the ongoing dissatisfaction with call light response times and the potential for resident frustration.
Plan Of Correction
No residents were identified in this citation. Residents residing in the facility have the potential to be affected by the deficient practice. The Administrator re-educated the Activities Director of the Guest/Resident Council policy and the proper use of grievance/concern forms to be used for concern resolution. The Administrator will audit resident council minutes to ensure guest/resident concerns are resolved in a timely manner and concern forms are completed appropriately. The Administrator will complete the audit monthly for four months to ensure substantial compliance. Results of the audits will be reported to the facility QAPI committee for review and recommendations. This plan of correction will be monitored at the routine Quality Assurance (QAPI) meeting until such a time it is identified by the committee that sustained substantial compliance has been achieved. The Administrator is responsible for attaining and maintaining compliance. Compliance Date: March 24, 2025