Failure to Ensure Functioning Grievance Process and Timely Call Light Response
Penalty
Summary
The facility failed to ensure a functioning grievance process for a resident with hemiplegia and muscle weakness, who reported that his call light was not answered in a timely manner. Observations revealed that the call light in the resident's room was continuously flashing and sounding for an extended period, and the issue persisted despite maintenance attempts to repair it. The resident and his roommate were provided with bells to ring for assistance, but both the resident and his family member reported that staff did not always hear the bells, resulting in delays in receiving help. The family member also noted that the resident's clothing was soiled due to these delays, and that he had to intervene to get staff attention. Interviews with facility staff, including the Social Service Director and Maintenance Director, confirmed ongoing issues with the call light system in the resident's room. The Maintenance Director stated that repairs had been attempted, including replacing parts and installing a new box, but the problem recurred and was not fully resolved. Documentation of efforts to address the malfunction was lacking, and the resident's grievance was marked as resolved despite the ongoing issue. The facility's grievance policy required prompt resolution and follow-up within a specified timeframe, but the persistent malfunction and inadequate interim measures indicated a failure to meet these requirements.