Failure to Address Resident Grievances and Call Light Response Issues
Penalty
Summary
The facility failed to ensure that residents' grievances were followed up with adequate and effective interventions to address and prevent recurring concerns, particularly regarding staff interactions with a dependent resident and nursing staff call light response times. During a Resident Council meeting, multiple residents reported persistent issues with insufficient nursing and laundry staff, especially on the night shift, resulting in long wait times for assistance. Residents described situations where staff would turn off call lights without providing help and noted that some residents, including one with severe cognitive impairment and total dependence for toileting, were ignored or dismissed by staff. Grievances about missed showers and lack of linens were also reported, with residents feeling their concerns were not believed or properly investigated. A review of grievances over a six-month period revealed repeated complaints about staff behavior, call light response times, and care quality, particularly during the night shift. Investigations into these grievances often relied on staff denials or incomplete audits, with little evidence of meaningful follow-up or resolution. For example, grievances filed on behalf of a dependent resident with dementia indicated she was left waiting for extended periods after soiling herself or was ignored when requesting help, but investigations concluded with minimal action or were dismissed based on staff statements. Call light audits conducted in response to complaints were inconsistently documented, lacked clear resolution, and did not specify whether response times were appropriate or if findings were communicated to the concerned residents. Despite ongoing concerns raised by the Resident Council and individual residents, the facility did not implement any performance improvement plans or other approaches to address the pattern of delayed call light responses, staff availability, or staff attitudes. The facility's grievance policy required immediate action and investigation, but documentation showed that grievances were not effectively addressed, and the Quality Assurance and Performance Improvement (QAPI) committee had not identified or acted on these recurring issues. As a result, residents felt discouraged from participating in council meetings, believing their concerns were not taken seriously or resolved.