Failure to Provide Grievance Information and Access to Residents
Penalty
Summary
The facility failed to provide residents and their representatives with information on how to file grievances or concerns, as required by regulation. Six out of eight residents interviewed during a confidential resident council meeting stated they did not know how to file a formal grievance, did not have access to grievance forms, and were unaware of the identity or contact information of the facility's grievance officer. These residents also reported never seeing any postings in the facility regarding grievance procedures and were not aware of the option to file grievances anonymously, despite having resided in the facility for six months or longer. Observations conducted in the facility confirmed that there were no prominent postings with instructions about the grievance procedure, no grievance forms readily available to residents, and no accommodations for submitting grievances anonymously. Interviews with the Assistant Director (AD) and the Administrator (ADM) revealed that the facility did not have a process in place for residents to independently access or submit grievance forms, either formally or anonymously. The AD and ADM both acknowledged that grievances were typically reported verbally to staff and then relayed to the ADM for resolution, with no system for residents to file grievances on their own or anonymously. A review of the facility's Social Services Department Policy and Procedures Manual indicated that while there was a policy stating residents and families have the right to file complaints without fear of reprisal, the actual practice in the facility did not align with these written procedures. The policy assigned responsibility to the social services director for establishing a mechanism for documenting and responding to complaints, but in practice, residents lacked access to the necessary forms, postings, and information required to exercise their grievance rights.