Deficient Grievance Process and Incomplete Investigation of Resident Complaints
Penalty
Summary
The facility failed to ensure a functioning grievance process for two residents, resulting in deficiencies related to the handling and resolution of grievances. In one instance, a resident verbally reported to the Social Service Assistant (SSA) that two CNAs were having personal conversations while providing care, including discussing their likes and dislikes for residents. The concern was relayed to the Administrator In Training (AIT), who assisted in filling out the grievance form but did not conduct an investigation or interview the resident. The Unit Manager (LPN) became aware of the complaint later and spoke to the resident, but there was no documentation of a thorough investigation. The resident reported that no one had come to talk to her about the concern and that she had not received a response from the facility regarding her grievance. Another incident involved a CNA reporting that a resident was found covered in feces and had been left in that condition for an extended period before being changed. The assigned staff member for the investigation was the same LPN/Unit Manager, who documented that the aide responsible was educated about the importance of prompt care. However, the section of the grievance form indicating whether the incident was reportable to the state agency was left blank, and the "Teachable Moment" document in the aide's personnel file was unsigned and not acknowledged by the Human Resource Director. The NHA confirmed that the resident should have been changed at least every two hours and acknowledged that the incident had the potential to be neglect, but the incident was not reported as required. Both cases demonstrate failures in the facility's grievance process, including lack of proper investigation, incomplete documentation, failure to communicate outcomes to residents, and not following reporting requirements for potential neglect. The facility's grievance policy requires prompt resolution, thorough investigation, and proper documentation, but these requirements were not met in the cases reviewed.
Plan Of Correction
F 585 Resident #1 was interviewed regarding the incident, and upon conclusion of the interview, the resident was satisfied with the outcome of the decision made by administration in relation to the submitted grievance. Reportable incident completed regarding this issue on. Additional services offered to the resident to provide additional support. Nursing assessments were completed to ensure there were no adverse effects to the resident. No adverse effects were noted. 2. Grievance log and grievances reviewed for the previous 3 months by NHA and Social Services Director (SSD). There were no other grievances that were found to be reportable events. Resident interviews were completed for residents with above 10 to ensure that there were no outstanding concerns or allegations that were not addressed. Skin assessments were completed for residents with less than 10. No additional findings at the time of evaluation. 3. Grievances are reviewed five times a week by the IDT to ensure a timely response. Grievance log and grievances will be audited weekly by SSD or designee, and NHA or designee to ensure that grievances are completed timely, and allegations of were addressed. This will be an ongoing practice implemented as part of the facility operations. Room rounds continue to be completed five times a week by IDT to ensure the resident is monitored and has no concerns. Education was completed with staff to review the grievance process. Education was provided by IDT members to staff. IDT was educated by the company VP of Risk Management. The grievance process was reviewed at the resident council meeting with residents. The process was reviewed by the Activities Director. Residents confirmed understanding of the process. 4. Audits will be reviewed at the QAA/QAPI meeting monthly for three months or until substantial compliance is achieved. The audits will be presented by the Social Services Director or designee.