Failure to Inform Residents of Grievance Process and Document Resolutions
Penalty
Summary
Surveyors found that the facility failed to ensure residents and their representatives were properly informed about the grievance process, including how to file grievances, who the grievance official was, and the contact information for independent entities such as the State agency and Ombudsman. There were no postings in prominent locations throughout the facility to notify residents of their rights to file grievances orally or in writing, nor was there information about the expected time frame for grievance review or the right to receive a written decision. The facility's policy required such notifications and prompt investigations, but these were not observed in practice. A review of grievance reports revealed that a resident's representative filed daily grievances over several months, covering issues such as care, safety, hygiene, financial matters, and rights violations. The documentation of these grievances consistently lacked specific resolutions, with reports often stating that issues remained ongoing and that the representative's expectations were considered unrealistic. The facility's records did not include written decisions confirming or denying the grievances, details of corrective actions taken, or the dates decisions were issued, as required by regulation. Interviews with facility staff, including the Director of Social Services and the Assistant Administrator, confirmed that the grievance process was not consistently followed. The Director of Social Services, who served as the grievance officer, did not keep track of grievances or their resolutions and was unsure if the grievance process was posted in the facility. The Assistant Administrator acknowledged ongoing difficulties with the resident's representative and confirmed that no satisfactory resolutions had been documented for the grievances. The lack of proper documentation and notification contributed directly to the deficiency cited.