Failure to Document and Resolve Resident Grievances from Council Meetings
Penalty
Summary
The facility failed to ensure that grievances voiced by residents during resident council meetings were properly documented, investigated, and resolved according to their established grievance policy. The policy required that all grievances, including those raised in resident council meetings, be documented in the grievance logbook and followed through to resolution, with analysis for trends. However, review of the grievance logbook for January through March 2025 showed that grievances from these meetings were not recorded, and there was no documentation of follow-up or resolution for the concerns raised. Four residents were identified as having voiced specific grievances during resident council meetings within this period. These included complaints about staff attitude, refusal to assist with personal care, and delays in medication administration. The residents involved had varying medical conditions, such as bladder infection, diabetes, kidney disease, left leg fracture, multiple sclerosis, and neurogenic bladder. All were assessed as cognitively able to make their needs known at the time of the incidents. Despite this, their grievances were not formally documented or addressed through the facility's official process. Interviews with facility staff revealed that the Activities Director, who coordinated the resident council meetings, attempted to resolve some grievances immediately but did not forward unresolved issues to the designated grievance officer or complete the required documentation. The Social Service Director, who was responsible for grievance oversight, was unaware of the specific grievances and could not ensure proper investigation or resolution. The Director of Nursing Services and the Administrator also confirmed that the correct grievance process was not followed, and specific resident concerns were not tracked or resolved as required.