Failure to Address Resident Grievances and Timely Response to Requests
Penalty
Summary
The facility failed to provide residents with information about the grievance process and did not ensure prompt or satisfactory resolution of concerns raised during resident council meetings. Multiple residents were unable to identify the facility grievance official, and the grievance process was not discussed at council meetings. Residents reported extended wait times for call light responses, with staff sometimes turning off call lights and not returning, or responding with negative attitudes and aggressive actions. Several residents expressed fear or humiliation when requesting assistance, and some experienced incontinence or pain due to delayed staff response. Concerns about housekeeping, such as catheter bins left in rooms and uncertainty about bed linen changes, were repeatedly raised but remained unresolved over several months. Review of resident council meeting minutes over several months showed that issues such as call light response times, catheter bins, and bed-making were consistently reported as unresolved. Management responses to these concerns were either delayed or insufficient, with some issues persisting for at least three months. The social services designee was unaware of the need to discuss the grievance process at council meetings and had not involved the area ombudsman. Grievances were handled by social services staff and forwarded to the ADON, but ongoing issues were simply referred to department heads without effective resolution.