Survey Results Not Accessible to Residents
Penalty
Summary
The facility failed to ensure that the results of the most recent federal recertification survey were readily accessible to residents, family members, and legal representatives. During a Resident Council Meeting, residents reported they were unaware of where to find the survey results and did not know that such results were available for them to read. Interviews with staff, including the Infection Preventionist (IP) and the administrator (ADM), revealed that staff were also unclear about the location of the survey results. The ADM indicated that the survey results binder was supposed to be by the front door, but upon inspection, the area was empty, and the binder was not present. The ADM stated it had been updated recently but was not available at the time of observation. Further, the Director of Nursing (DON) acknowledged that if the survey result binder was not easily available, residents would not be able to know the results from the last survey or what the facility was working on to address identified problems. The DON was unsure how long the binder had been unavailable. A review of the facility's policy confirmed that residents have the right to examine survey results, as guaranteed by federal and state laws. This deficiency affected a census of 75 residents and was based on direct observation, interviews, and record review.