Grievance Forms Not Accessible to Residents
Penalty
Summary
The facility failed to ensure that grievance forms were available and accessible to residents on all three nursing units, specifically the second, third, and fourth floors. During a facility tour, it was observed that there were no grievance forms readily accessible to residents without them having to ask for assistance. The facility's policy states that grievances may be filed anonymously through secure drop boxes located on each unit, but these forms were not present or accessible as required. Additionally, a review of the facility's grievance logs over a six-month period revealed only one grievance filed, suggesting limited resident access or awareness of the grievance process. Interviews with staff indicated that the social worker typically interviews anyone with a concern and fills out the grievance form on their behalf, rather than residents having direct access to the forms. This practice does not align with the facility's policy or regulatory requirements, which mandate that residents must be able to file grievances independently and anonymously if desired. The lack of accessible grievance forms and reliance on staff to initiate the process contributed to the deficiency cited by surveyors.
Plan Of Correction
Grievance forms have been placed on all units next to the grievance submission box. Residents will receive education on the grievance process at the resident council meeting. The resident welcome book has been updated to include information regarding grievances and the grievance officer, and will be distributed to all new and current residents. The grievance officer or designee will conduct weekly audits to ensure forms are available for residents and to collect any grievances that may have been submitted. The grievance policy has been updated. Grievances will be reported at quarterly QAPI meetings.