Failure to Respond Timely to Resident Grievances and Preferences
Penalty
Summary
The facility failed to respond in a timely manner to resident concerns for two residents regarding food preferences, meal quality, and ambulation assistance. One resident, who had a history of traumatic brain injury, cognitive communication deficit, and cancer with significant weight loss, reported ongoing dissatisfaction with the meals provided, including issues with food type, temperature, and lack of dietary accommodations. The resident and his wife stated they had complained almost daily since admission but were unaware of how to file a formal concern. The dietary manager was not aware of the resident's food preferences, and the required paperwork was found incomplete in the resident's room. Additionally, requests to eat in the dining room and be out of bed for meals were not communicated to the care staff, and no concern forms were completed or provided for these ongoing complaints. Another resident with dementia, depression, and mobility difficulties requested, along with her family, to be walked to the bathroom daily instead of being transported in a wheelchair. Although the care plan indicated she required only one-person assistance with a walker and therapy notes confirmed her ability to ambulate with minimal help, the facility denied the request, citing safety concerns without documented justification. The DON was unable to locate any risk/benefit analysis or documentation supporting the decision to refuse the resident's request, nor were any concern forms found to address the resident's or family's repeated concerns. In both cases, the facility did not provide evidence of a timely or effective response to resident grievances, failed to document or communicate resident preferences and concerns, and did not ensure that residents and their families were informed about the grievance process. These actions resulted in the residents' needs and preferences not being addressed as required by facility policy.