Failure to Address Resident Council Concerns in a Timely Manner
Penalty
Summary
The facility failed to address concerns raised by the Resident Council in a timely manner, as evidenced by a review of Resident Council meeting minutes, policy documents, and staff and resident interviews. Concerns about call light wait times were repeatedly mentioned in several meetings, and issues with ice water were also raised. However, the minutes did not document any resolutions to these concerns, and the facility's policy requiring concerns to be documented, distributed to department heads, and followed up through the Resident Grievance Procedure was not followed. Staff interviews confirmed that concern forms were not used, concerns were not formally presented to department heads, and there was no process to communicate resolutions back to the Resident Council. A resident reported ongoing issues with excessive call light wait times, including a specific instance of a two-hour wait. The Director of Activities, who presides over Resident Council meetings, acknowledged that resolutions to concerns were not brought back to the Council. The Social Service Designee maintained a separate concern log for other issues but did not handle Resident Council concerns. The Administrator confirmed there was no documentation of complaint resolution for Resident Council issues, and the last call light audit was conducted prior to the most recent meeting where call light concerns were still being reported. This deficiency was identified during an investigation under a specific complaint number and had the potential to affect all residents in the facility.