Failure to Resolve and Communicate Grievance Outcomes Related to Call Bell Response
Penalty
Summary
The facility failed to make ongoing efforts to resolve grievances and provide timely follow-up with residents regarding the status of their complaints, specifically related to call bell response times. Facility policy requires the grievance official to track all grievances through to their conclusion and to issue written grievance decisions to residents. However, interviews with residents and staff, as well as a review of grievance forms, revealed that multiple residents experienced excessive call bell wait times, sometimes exceeding one hour, and did not receive confirmation or updates regarding the resolution of their grievances. In one instance, a resident reported waiting over an hour for a call bell response, and another grievance indicated residents were left in urine-soaked beds for extended periods due to staff being unaware of their incontinent status. Despite these grievances being filed, there was no evidence that written resolutions were provided to the residents involved. Staff interviews confirmed that there was no consistent process for meeting with residents to review grievance resolutions, and the grievance official did not have a system in place to track filed and resolved grievances as required by policy. Observations further supported these findings, with a call bell going unanswered for 47 minutes and a foul odor of feces present in a resident's room, indicating a lack of timely response. The facility was unable to provide documentation that resolutions to the call bell response time issues were communicated to residents, despite multiple grievances being filed about the ongoing problem.