Failure to Promptly Resolve and Document Resident Grievances
Penalty
Summary
The facility failed to ensure prompt efforts were made to resolve grievances voiced by residents, particularly those raised during Resident Council meetings over a period of several months. Resident Council minutes from three separate months documented ongoing concerns about delayed call light responses and inadequate staff assistance, especially during evening and weekend shifts. Despite these recurring complaints, a review of the facility's grievance logs revealed no corresponding entries or documentation of these issues being formally addressed as grievances. Two residents, both cognitively intact, reported continued difficulties in receiving staff assistance. One resident filed a grievance regarding lack of staff assistance, but the investigation only noted the nurse aide's location at the time and did not document notification of the resident's representative. The other resident filed a grievance about both staff assistance and maintenance of an air mattress; the investigation only addressed the mattress issue, leaving the staff assistance concern unresolved and the resolution date section blank. Both residents continued to report ongoing problems with staff assistance during interviews. Interviews with facility staff, including the Activity Director and Social Service Director (who also served as the Grievance Coordinator), confirmed that while concerns were discussed in meetings and some actions were taken, the formal grievance process was not consistently followed. The facility's own policy requires that all grievances, including those voiced during Resident Council meetings, be documented, investigated, and resolved promptly, with appropriate follow-up and communication to the resident. However, the absence of documentation and incomplete investigations indicate that these procedures were not adhered to in these cases.