Failure to Ensure a Functioning Grievance Process
Penalty
Summary
The facility failed to ensure a functioning grievance process for two residents, as required by state statute. For one resident, a grievance was verbally communicated to the Social Service Assistant regarding two CNAs having personal conversations while providing care. The grievance form was completed, and the CNAs were identified and verbally educated. However, there was no documentation indicating whether the resident was satisfied with the resolution, and the resident later stated that no one had spoken to her about the concern or provided a response. Interviews with staff revealed confusion about who was responsible for investigating and resolving the grievance, with some staff unaware of the complaint or not participating in the investigation. Another incident involved a resident who was found covered in feces after reportedly waiting for an extended period before being changed. The CNA assigned to the resident was educated about the importance of prompt care, and a "teachable moment" document was placed in the personnel file. However, the form was not signed by the presenter or recipient, and the section indicating whether the grievance was reportable to the state agency was left blank. The resident was totally dependent on staff for toileting, and the care plan reflected this need. The NHA confirmed that the resident should have been changed at least every two hours and acknowledged that the incident could be considered neglect, but it was not reported. Both cases demonstrate a lack of proper documentation, follow-up, and communication with the residents regarding their grievances. The facility did not ensure that grievances were thoroughly investigated, resolved in a timely manner, or that residents were informed of the outcomes, as required by policy and regulation. The absence of clear documentation and communication contributed to the deficiency cited by surveyors.
Plan Of Correction
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. Grievance log and grievances reviewed for the previous 3 months by the 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 were noted at the time of evaluation. Grievances are reviewed five times a week by the IDT to ensure a timely response. The grievance log and grievances will be audited weekly by the SSD or designee, and NHA or designee, to ensure that grievances are completed timely and that allegations 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 the 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, and the IDT was educated by the company VP of Risk Management. The grievance process was reviewed at the resident council meeting with residents. Residents confirmed their understanding of the process. 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.