Failure to Address Resident Grievance Regarding Delayed ADL Care
Penalty
Summary
The facility failed to address a resident's grievance regarding delayed response to call lights and untimely provision of Activities of Daily Living (ADL) care. The resident, who was admitted with acute kidney failure, heart failure, and depression, was observed to be visibly upset and reported having waited nearly three hours to have her soiled brief changed. She stated that she had activated her call light multiple times, staff would enter, turn off the call light after being told of her need, and then leave without providing the requested care. The resident also reported having previously discussed these concerns with the Director of Nursing (DON), who did not follow up or resolve the issue. Interviews with facility staff confirmed that the resident's complaints had not been formally documented as a grievance, nor had any follow-up been conducted to ensure resolution. The DON acknowledged awareness of the resident's complaints but admitted that no formal grievance process was initiated. The Administrator, who serves as the grievance officer, also confirmed that the complaint should have been documented and addressed as a grievance, but this was not done. Facility policy requires grievances to be documented and responded to within five working days, with immediate action for alleged violations of resident rights, but these procedures were not followed in this case.