Failure to Provide Written Grievance Decisions
Penalty
Summary
The facility failed to ensure that residents had the right to obtain a written decision regarding their grievances, as evidenced by the case of a resident whose Health Care Proxy repeatedly requested written results for filed grievances but did not receive them. The facility's policy, dated 11/17/2017, required that residents or their representatives be notified of their right to obtain a written decision regarding grievances. Despite this policy, the Health Care Proxy of a resident with severely impaired cognition, as identified in the Minimum Data Set dated 03/18/2024, requested written confirmation of grievance outcomes on multiple occasions via email to the Facility Administrator. These grievances included issues such as the resident being found wet and soiled, concerns about an unlicensed social worker diagnosing medical conditions, and inaccurate comments made by the Administrator during a care plan meeting. The Director of Social Service, who was responsible for investigating grievances, stated that they provided verbal outcomes but did not provide written results. The Facility Administrator confirmed that the Social Service and Interdisciplinary Team were responsible for providing grievance results to residents or their representatives. Despite setting up meetings for the Health Care Proxy to review grievance copies in person, the meetings were either not attended or attended late by the Health Care Proxy, and no written responses were mailed as requested. The facility's failure to provide written grievance decisions as requested by the Health Care Proxy constitutes a deficiency in adhering to the residents' rights as outlined in the facility's grievance policy.
Plan Of Correction
Plan of Correction: Approved April 11, 2025 I. Immediate Corrections Grievances provided Resident #1's Emergency Contact. Written documentation was provided per request, and the concerns were addressed in alignment with the facility's Grievances Policy. Follow-up communications were also conducted to ensure the complainant was informed of the outcome and resolution. II. Identification of Other Residents A full-house grievance audit was conducted. This review confirmed that all grievances submitted during the specified period were fully investigated, resolved, and appropriately closed out. Interviews with residents and/or their emergency contacts confirmed satisfaction with the resolutions. Documentation was provided to those who requested it, demonstrating transparency and adherence to grievance protocol. III. Systemic Changes The Facility Grievance Policy was reviewed, and no revisions were necessary. Upon review, it was determined that the policy remains comprehensive, current, and in full compliance with 42 CFR §483.10(j). Nevertheless, as a proactive measure, all facility Social Workers were re-educated on the policy to reinforce expectations regarding grievance documentation, resolution timelines, and communication with residents and families. IV. QA Monitoring The Director of Social Work or designee will conduct a weekly audit for 4 weeks then a monthly audit for an additional two months to ensure that all grievances are completed in the appropriate time frame and if a copy of the grievance is requested it will be provided. Audit results will be presented to the QAPI committee during the quarterly meetings. The QAPI committee will review the findings and determine if any further corrective action or policy enhancement is warranted. Person Responsible: Director of Social Services