Failure to Promptly Resolve and Track Resident Grievances
Penalty
Summary
The facility failed to make prompt efforts to resolve resident grievances, specifically for three residents who reported missing personal items. During a confidential group meeting, multiple residents expressed dissatisfaction with the grievance process, stating that concerns were not addressed in a timely manner and that they often did not receive feedback or solutions. Review of Resident Council meeting minutes over several months showed that concerns raised by residents were not followed up on or resolved, as subsequent meetings consistently recorded no old business to discuss or follow up. Specific examples included residents reporting missing items, such as clothing and blankets, to staff without any documented resolution or communication back to the residents. Interviews with staff revealed a lack of awareness and adherence to the facility's grievance reporting procedures. Several CNAs and RNs were unaware of the required forms or processes for documenting and tracking grievances related to missing items. The facility's policy on missing items did not include a mechanism for tracking or reporting grievances, nor did it specify how to keep residents informed of the status of their concerns. As a result, grievances were not consistently documented or addressed, and residents were left without resolution or updates regarding their reported issues.