Failure to Communicate Grievance Resolutions to Residents
Penalty
Summary
The facility failed to provide appropriate follow-up, response, and rationale to residents regarding grievances raised during resident council meetings and through individual complaints. According to the facility's grievance policy, the grievance official or designee is required to respond to concerns within three working days, acknowledging receipt and describing steps taken toward resolution. However, record reviews and interviews revealed that while grievances were documented and some actions were taken (such as staff education or cleaning the patio), there was no evidence that the facility communicated the outcomes or resolutions back to the residents or the resident council. Interviews with residents who regularly attended resident council meetings indicated that they were unaware of how grievances were handled after being raised. Residents reported that while department heads sometimes addressed issues during meetings, there was no follow-up or feedback provided regarding the resolution of their concerns. Specific issues brought up by residents included call light response times, unchanged linens, cigarette butts in the smoking area, cold food, delayed room trays, poor communication from therapy, and cleanliness of rooms and bathrooms. Despite these concerns being documented in meeting minutes and grievance forms, residents stated they did not know the outcomes or how to file grievances properly. Staff interviews confirmed the lack of follow-up. The activities director stated that department managers were supposed to bring back resolutions to the next resident council meeting, but this did not consistently occur. The social services director, who served as the grievance official, acknowledged that documentation of follow-up with residents or families was missing from grievance forms for several months. This failure to communicate resolutions left residents uninformed about the actions taken in response to their concerns.