Failure to Address and Resolve Resident Grievances
Penalty
Summary
The facility failed to establish and maintain an effective system for addressing and resolving resident grievances, as required by policy. Review of resident council (RC) meeting minutes over a six-month period revealed that residents consistently voiced concerns, such as overflowing trash containers, insufficient shower aides, excessive nighttime noise, untimely bed making, and issues with laundry detergent causing itching. Despite these recurring complaints, there was no evidence that the facility documented these grievances or provided follow-up or resolution to the residents. Residents interviewed confirmed that while previous meeting minutes were reviewed, there was no follow-up or notification regarding the status or resolution of their concerns. Additionally, the facility did not follow its grievance process for a resident who reported missing personal clothing. The resident stated they had informed aides and laundry staff about the missing pants, but no grievance form was completed, and the issue remained unresolved. Staff interviews revealed inconsistent understanding and application of the grievance process, with some staff indicating that grievance forms were primarily used for family complaints or only when residents were visibly upset. The designated grievance official, the Social Services Director, reported not receiving any grievance forms related to the missing clothing or other concerns raised in RC meetings. A review of the facility's grievance log showed no documented grievances from the RC meetings or the resident with missing clothing during the review period. The facility's policy requires that all grievances be documented, investigated, and followed up with written decisions, but this process was not followed. As a result, residents repeatedly reported the same issues without resolution, and their concerns were not formally addressed or tracked according to policy.