Ineffective Grievance Program and Unresolved Resident Concerns
Penalty
Summary
The facility failed to implement an effective grievance program, as evidenced by ongoing issues with call light response times and other resident concerns that were not adequately addressed. Over a six-month period, the grievance logs revealed repeated complaints about call light response times, with no clear resolution or improvement. Despite staff education efforts, the problem persisted, particularly during evening and weekend shifts, as noted by resident council members and confirmed by interviews with staff. Additionally, the grievance logs and resident council minutes highlighted other unresolved issues, such as staff behavior, customer service in the dining room, and delays in returning clean clothes. These grievances were marked as resolved with staff education, but the recurring nature of the complaints suggests that the underlying issues were not effectively addressed. The resident council minutes often indicated that old business was reviewed and accepted, but without confirmation that the issues were fully resolved, leading to continued dissatisfaction among residents. Interviews with the Activities Director and Social Service Director revealed gaps in the grievance process, including a lack of follow-up on grievances and insufficient audits during evening, night, and weekend shifts. The facility's grievance policy required prompt resolution of grievances, but the ongoing nature of the complaints and the lack of effective corrective actions indicate a failure to adhere to these guidelines. This deficiency in the grievance process resulted in unresolved resident concerns and a lack of confidence in the facility's ability to address and resolve issues effectively.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. (1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. Resident #1 was discharged on. On, the NHA/Designee immediately re-educated the Activity Director on the components of F585 with an emphasis on ensuring the Resident Council forms are completed with accuracy and grievances from Resident Council are acknowledged, documented, and resolved. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken. On, NHA/Designee completed a quality review on grievances from Resident Council for the past six months () to ensure voiced concerns were acknowledged, documented, and resolved. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur. On, Vice President of Operations re-educated the management staff on the components of F585 with an emphasis on ensuring grievances from Resident Council are acknowledged, documented, and resolved. Newly hired management staff will be educated by the NHA or designee on ensuring grievances from Resident Council are acknowledged, documented, and resolved. On, Resident Council meeting will increase in frequency from biweekly to weekly to ensure grievances from Resident Council are acknowledged, documented, and resolved. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place. Administrator/Designee to conduct audits weekly for 4 weeks, biweekly for 4 weeks, then monthly for 1 month to ensure the Resident Council forms are completed with accuracy and grievances from Resident Council are acknowledged, documented, and resolved. The findings of these quality monitoring reports are to be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines substantial compliance has been met.