Failure to Address Resident Grievances
Penalty
Summary
The facility failed to ensure that grievances were promptly documented, investigated, tracked, and resolved for a resident, resulting in ongoing frustration and unresolved grievances. The resident, a cognitively intact female with diagnoses including hypertension, Guillain-Barre Syndrome with paraplegia, major depression, and anxiety disorder, expressed repeated frustration over the constant yelling of nearby residents. Despite informing staff of her grievances, no changes were made, and the resident was not familiar with the facility's grievance process. Observations and interviews revealed that the resident and her roommate preferred to keep their door closed due to the noise, and the resident resorted to using ear buds to cope with the situation. Certified Nurse Aides (CNAs) working on the hall confirmed that complaints about the yelling were common and reported to the Unit Manager. However, the grievances were not documented or resolved, leading to increased frustration for the resident, who even began yelling back, which was uncharacteristic for her.
Plan Of Correction
Element 1: Resident #52 no longer resides in the facility. Resident #52 concerns were addressed with the Assistant Administrator. A white noise machine was purchased to assist with the noise level in the hall. Follow-up visit was completed, and the resident states the machine has helped. Concern form signed and completed by the Administrator. Element 2: The Administrator/Designee will complete an audit of residents to ensure concerns have been documented on grievance forms. Any new concerns will be documented per the QA policy and addressed. Element 3: The QAPI Committee will review the Quality Assistance Procedure policy and deem it appropriate. The Administrator and Director of Nursing have been educated by Regional Director of Operations on the QA Policy. Staff will be educated on the QA policy/grievance policy to ensure concerns are addressed appropriately. Staff to turn concern forms to the administrator daily. Administrator will follow up with appropriate departments to ensure concerns are addressed. Element 4: Administrator/Designee will complete random weekly audits for 4 weeks and then monthly until substantial compliance is achieved, ensuring concern forms and follow-up are completed. Audit findings will be presented to the facility QAPI Committee and will only be discontinued with substantial compliance and with approval of the facility QAPI Committee. The Administrator is responsible for achieving and maintaining compliance.