Failure to Address and Document Resident Council Grievances
Penalty
Summary
The facility failed to ensure that grievances and recommendations from the Resident Council regarding resident care and life in the facility were acted upon promptly. Multiple residents voiced concerns during a special Resident Council meeting about delayed call light responses, untimely medication administration, and insufficient assistance with activities of daily living such as bathing and showering. Review of meeting minutes and grievance records over several months revealed repeated reports of these issues, including lack of showers, not being assisted out of bed, and inadequate staffing. However, there was no documented evidence that these grievances were investigated or addressed in a timely manner, nor was there follow-up communication to residents regarding the status of their complaints. Facility policy required that grievances be investigated within three working days and that immediate action be taken to prevent further violations of resident rights. Despite this, interviews with facility leadership confirmed that grievances discussed in Resident Council meetings were written up and distributed to relevant departments, but there was no process in place to ensure that concerns were resolved or that old business was discussed in subsequent meetings. No audits were conducted to verify resolution of grievances, and meeting minutes lacked documentation of follow-up actions taken by staff.