Failure to Inform Residents of Survey Results and Binder Location
Penalty
Summary
The facility failed to ensure that residents were aware of and reminded about the results of previous state recertification surveys, as well as the location of the binder containing these results. During a resident council meeting, five residents who were alert, oriented, and had intact cognition scores (BIMS scores ranging from 14 to 15) stated they did not know the results of the previous surveys or where the survey binder was located. These residents had various medical conditions, including acute respiratory disease, chronic pulmonary edema, atrial fibrillation, diabetes mellitus, peripheral vascular disease, cellulitis, hyperlipidemia, osteoarthritis, congestive heart failure, hemiplegia, hypertension, and seizures. Interviews with facility staff revealed further gaps in communication and knowledge. The Activity Director, who had been employed at the facility for twenty-five years, was unaware of the survey results and the location of the survey binder, suggesting it might be in the administrator's office. The administrator confirmed that the Activity Director should know the binder's location to inform and remind residents. The Director of Nursing also verified that all staff should be aware of the binder's location. A review of the facility's policy and procedure on access to survey results indicated that survey results and approved plans of correction should be available in a readable form and accessible to residents without needing to ask staff. The policy also stated that residents should be notified at least annually during Resident Council meetings, and meeting minutes should reflect that survey results were communicated. However, the findings showed that these procedures were not followed, as neither residents nor key staff were aware of the survey results or the binder's location.