Failure to Document and Resolve Resident Grievances
Penalty
Summary
The facility failed to ensure that resident grievances were properly documented and resolved, as required by policy and regulation. Multiple residents reported ongoing issues with meal choices, meal ticket accuracy, and the honoring of food preferences and dislikes. For example, one resident repeatedly received meals with items listed as dislikes on her meal ticket, such as gravy, and did not receive requested alternatives like a chef salad, despite having standing orders. Another resident with a history of ulcers received tomatoes on her tray, which she had specifically requested to avoid. These concerns were voiced to staff but were not consistently documented as grievances or followed up with appropriate dietary consultations. Resident Council and Food Committee meetings revealed recurring concerns about meal ticket errors and other issues, such as staff using personal phones during care, call lights not being answered, and cleanliness problems. Despite these issues being raised repeatedly in meetings and committee minutes, there was a lack of corresponding documentation in the grievance log for several months. Residents and their representatives also reported that grievances were not being followed up on or communicated back to them, and that the process for addressing grievances was unclear or inconsistently applied. In some cases, grievances submitted by family members or surrogates were not fully documented or tracked, and some issues were marked as resolved without evidence of comprehensive follow-up. Interviews with facility staff, including the Nursing Home Administrator, Certified Dietary Manager, and Social Services staff, confirmed gaps in grievance documentation and tracking. Staff acknowledged that grievances were not always logged, especially those arising from committee meetings or voiced informally by residents. The facility's own policy requires prompt documentation, investigation, and written resolution of all grievances, but records showed that this process was not consistently followed. As a result, residents' rights to voice grievances without discrimination or reprisal, and to have those grievances promptly addressed, were not upheld.