Failure to Inform and Implement Grievance Process
Penalty
Summary
The facility failed to inform and educate residents about the grievance process and did not effectively implement procedures for documenting, tracking, and resolving grievances. During a confidential group meeting, all six residents present reported that they repeatedly discussed the same concerns in resident council meetings without resolution. These residents were unaware that they could have their private concerns documented on a form, that staff could assist them in completing the form, or that they could submit concerns anonymously. They also did not know that concern forms were available or how to access them, but indicated they would use the forms if they were accessible. Observations revealed that blank concern forms were stored in a binder on a shelf located 4-5 feet up on the wall in a sitting area near the main lobby, making them not easily accessible to residents. Interviews with staff, including an LPN and two Activity Associates, showed a lack of awareness about the location and use of concern forms. The LPN stated she did not know where to find the forms or assist residents with them, and one Activity Associate was unfamiliar with the forms altogether. The other Activity Associate, who conducted resident council meetings, reported that she emailed concerns to relevant departments but did not follow up to ensure concerns were addressed, only discussing responses from previous meetings if available. Further interviews with facility leadership, including the Nursing Home Administrator and DON, confirmed that concern forms were not placed in areas frequented by residents and were posted high on the wall, making them difficult to access. The DON also noted that staff, rather than residents, typically initiated the concern forms. As a result, the facility did not ensure that residents were properly informed about their right to file grievances, did not make the process accessible, and failed to document, track, and record the resolution of grievances as required.
Plan Of Correction
1. The facility moved concern/grievance forms to a tabletop location that is prominent and easily accessible in the lobby. A prominent notice was placed to guide residents to the location. 2. All residents who have concerns about their care have potential to be affected. 3. The facility created a log of concerns and grievances to monitor follow-up and ensure each concern is resolved. The log also enables the facility to track and trend concerns to identify opportunities for continuous quality improvement. The facility will report the number and nature of concerns, resolution status, and trends at monthly Quality Assurance Performance Improvement (QAPI) meetings, where the QAPI Committee will use the information to direct performance improvement projects as warranted. The facility will also provide written information to all residents on the right to air concerns or grievances, and the location of self-reporting forms. This information will be provided to the Resident Council at the July meeting. Going forward, this information will also be included in the admission packet. Education will be provided to all employees about the right to air concerns and grievances, and how residents can submit concerns or grievances using forms that are available in the lobby or with confidential help from an employee. Education will include how these are tracked for continuous quality improvement. 4. During routine daily leadership rounds, each leader will interview at least one resident for awareness how to report a concern or grievance for at least the next 12 weeks. During monthly QAPI meetings the committee will review the number, nature and status of concerns and will determine if opportunities are present for performance improvement. 5. The executive director is responsible for compliance.