Failure to Address and Follow Up on Resident Council Grievances
Penalty
Summary
The facility failed to maintain an effective system to ensure that grievances and concerns raised during Resident Council meetings were addressed and followed up on. Review of Resident Council meeting minutes from October 2024 through May 2025 revealed that the documentation did not consistently include sections for follow-up on previously raised issues, particularly for nursing-related concerns. Specific concerns, such as residents not receiving pain medication when supplies ran out and reports of nursing staff being mean or rough, were documented in the minutes but lacked evidence of follow-up or resolution in subsequent meeting notes or grievance logs. In several instances, concerns raised in one meeting were not addressed in the following meetings or documented in the facility's grievance logs, and there was no indication that department heads, including the DON, were consistently made aware of these issues. Interviews with the Activity Director and DON revealed inconsistent communication practices regarding how concerns from Resident Council were relayed to department heads. The Activity Director reported emailing department heads and discussing concerns, but documentation of responses was inconsistent, and the DON was unaware of several concerns raised. Additionally, some concerns that could be interpreted as allegations of abuse were not escalated or documented as such. The lack of a structured process for tracking and addressing grievances resulted in unresolved issues persisting across multiple months, with no clear documentation of investigation or resolution.