Survey Results and Plan of Correction Not Readily Accessible to Residents
Penalty
Summary
The facility failed to ensure that the results of the most recent federal surveys and corresponding plans of correction were readily accessible to all residents. During a confidential group meeting, all six residents present reported that they were unaware they could read the survey reports and did not know who to ask or where to find them. An observation revealed that the binder containing survey reports was placed on a shelf approximately 4-5 feet up on the wall in a sitting area next to the main lobby, making it difficult for residents to access. Interviews with staff further confirmed the deficiency. An LPN stated she did not know where the survey reports were located or how residents could access them. The Nursing Home Administrator acknowledged that the reports were kept in an area not frequently visited by residents and were not easily accessible. Additionally, an Activity Associate who conducts monthly resident council meetings was not aware of how residents could obtain access to the survey reports. These findings demonstrate that the facility did not make survey results and plans of correction readily accessible to residents as required.
Plan Of Correction
The facility moved the binders containing survey results to a prominent location in the lobby on a table that residents, family members, and legal representatives can reach either standing or sitting in a wheelchair. The public binders include survey results for the current year and the previous 3 years along with plans of correction. The facility also placed a prominent notice at the table stating that survey and advocacy information is available here. All residents who want this information have the potential to be affected. The facility created the policy: Facility Required Postings. The facility created the flier "Where to Find Survey Reports" and will distribute it to all patients and residents. The flier will also be added to the facility admission packet. Education will be provided to all employees about where survey information can be found. The resident council will also be given this information at the July meeting. During daily routine leadership rounds, each leader will interview at least one resident for awareness where to locate survey results, for at least the next 12 weeks. The executive director is responsible for compliance.