Failure to Timely Respond to Resident Grievances and Communicate Care Needs
Penalty
Summary
The facility failed to respond in a timely manner to grievances raised by two residents, as evidenced by interviews, observations, and record reviews. One resident, a 90-year-old female with diagnoses including vascular dementia, kidney disease, and major depressive disorder, was not her own responsible party and served as the resident council president. She reported ongoing issues with wheelchair comfort and meal quality, specifically noting a decrease in fresh fruit offerings and dissatisfaction with bread options. Despite her participation in resident council meetings, she was unaware of any formal written grievance forms and expressed that discussions during meetings did not lead to resolutions, stating, "nothing gets done." Review of resident council minutes from several months revealed repeated dietary complaints, including concerns about dessert amounts, meat quality, bread variety, and the availability of fresh fruit and vegetables. These concerns were documented in meeting minutes and a grievance/complaint report was submitted to the Nursing Home Administrator on behalf of the resident council, indicating that concerns were not being fully communicated or resolved. The administrator acknowledged receipt of the grievance but did not provide evidence of prompt resolution or written decisions to the residents as required. Additionally, the occupational therapist confirmed that while a low back cushion had been provided to the resident for wheelchair comfort, there was no documentation or communication to nursing staff regarding its use after therapy ended. The resident continued to experience discomfort and improper positioning in her wheelchair, and nursing staff had not been instructed to perform frequent positioning checks until prompted by the therapist during the survey. These findings demonstrate a lack of timely and effective response to resident grievances and insufficient communication among staff regarding resident care needs.
Plan Of Correction
F585 1. Residents #10 and #40 still currently reside in the facility. Their grievances were immediately documented and addressed between by 4/23/2025. 2. Current residents have the potential to be affected by this deficient practice. A resident council meeting will be held on 4/22/2025, to ensure current residents can express their concerns. A weekly resident council will be held x 4 weeks to ensure the current residents' needs are addressed. 3. Resident Council policy was reviewed and revised. Department heads and facility managers were educated by the Admin/designee between by 4/23/2025 on proper procedures. 4. The QAPI committee has directed the DON/designee to perform random weekly audits on 20% of current residents in the facility, to ensure their concerns are being addressed. The Administrator is responsible for ensuring that substantial compliance is attained through the Plan of Correction and is maintained thereafter. The results will be provided to the QAPI Committee for further follow-up and review.