Failure to Resolve Resident Grievances and Inform Residents of Grievance Process
Penalty
Summary
The facility failed to provide prompt efforts to resolve multiple grievances raised by a group of nine residents, as required by federal regulations. During a Resident Council meeting, residents reported ongoing issues such as prolonged call light response times, dissatisfaction with food palatability and variety, lack of bedtime snack distribution, limited group activities due to transportation issues, and concerns about staff availability and attitude. Residents expressed that their complaints were not being addressed or followed up on, and that they were not informed about the grievance process or the existence of a grievance form. When the grievance form was presented during the meeting, several residents indicated it was their first time seeing it and were unaware of how to file grievances or to whom they should report their concerns. Review of Resident Council meeting minutes from December through May revealed a lack of documentation regarding the resolution or follow-up of previously raised concerns. Old business sections in the minutes were often left empty, and unresolved issues were not consistently carried over or addressed in subsequent meetings. The March meeting minutes were missing, and the Administrator explained that the meeting was not held due to a COVID-19 outbreak, but there was no documentation of postponement or attempts to resolve outstanding issues. The Administrator also indicated a lack of awareness regarding her ability to attend council meetings to address concerns directly. Specific grievances included the absence of field trips since the facility sold its bus, repetitive and unappealing food menus, staff failing to provide or distribute bedtime snacks, and staff not responding promptly to call lights or making excuses about unavailable equipment. Residents also reported that staff sometimes turned off call lights without fulfilling requests and were observed socializing or using cell phones instead of attending to residents' needs. One resident with diabetes was unaware of the availability of bedtime snacks and had not received them. The facility's failure to inform residents about the grievance process and to document or resolve ongoing concerns resulted in unresolved grievances and resident frustration.