Failure to Address and Document Resident Grievances
Penalty
Summary
The facility failed to ensure that resident grievances were properly addressed and documented, as required by policy and regulation. Over a six-month period, concerns raised during resident council meetings, such as issues with cold food, call light response times, and dietary services, were not consistently logged as grievances, with only one grievance documented for the entire period. The Activities Director reported transcribing concerns from resident council meetings and submitting them as grievances to Social Services or the Nursing Home Administrator, but there was no evidence of follow-up or resolution communicated back to the resident council. Individual residents and their representatives also reported grievances that were not documented or resolved. One resident, who was cognitively intact and had hemiplegia, reported being treated rudely by a CNA and discussed the incident with an LPN and a Unit Manager. However, there was no record of a grievance being filed for this incident. Another resident's representative reported repeatedly raising concerns about call light response times to various staff members without receiving any resolution or follow-up. Similarly, a third resident's representative stated that concerns discussed with staff and the administrator were not addressed or followed up on, and no grievances were logged for these issues. Interviews with staff responsible for grievance management confirmed that grievances were not consistently logged or tracked for the concerns raised by residents and their representatives. The Social Services staff member acknowledged that grievances should have been written for the incidents described but were not. The facility's grievance policy outlines a process for logging, investigating, and resolving grievances, including prompt follow-up and written decisions, but this process was not followed in the cases reviewed. As a result, the facility did not ensure that residents' rights to voice grievances without discrimination or reprisal were honored, nor did it make prompt efforts to resolve grievances as required.