Ineffective Grievance Program and Unresolved Resident Concerns
Penalty
Summary
The facility failed to implement an effective grievance program, as evidenced by ongoing issues with acknowledging, documenting, and resolving resident concerns. Over a six-month period, the grievance logs revealed persistent issues with call light response times, which were not adequately addressed. Additionally, there were grievances related to Activities of Daily Living (ADL) care not being provided, medications being left at the bedside, and medications not being administered in a timely manner. Despite staff education efforts, these issues continued to be a concern for residents. The Resident Council Minutes consistently showed unresolved grievances, with recurring complaints about call light response times, staff behavior, and dining services. The minutes also indicated that old business items were not always resolved, as evidenced by unchecked boxes meant to confirm resolution. Residents expressed dissatisfaction with various aspects of care, including the timeliness of laundry services, the availability of snacks, and the responsiveness of staff to their needs. Interviews with facility staff, including the Activities Director and Social Service Director, revealed that the grievance process was not effectively addressing resident concerns. The Social Service Director explained the grievance process, but the facility's performance improvement plan did not include audits for evening, night, and weekend shifts, which were times when grievances were notably unresolved. This lack of comprehensive auditing contributed to the ongoing issues with the grievance program.
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 provided immediately re-educated to the Activity Director on the components of N042 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 N042 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.