Failure to Establish and Implement Grievance Policy and Process
Penalty
Summary
The facility failed to establish and implement a grievance process to ensure the prompt resolution of all grievances related to residents' rights. Record review revealed the absence of a Grievance Log, and interviews confirmed that grievances were handled informally as they arose, without documentation or a formal tracking system. The DON stated that there was no written form available for residents or families to submit concerns or grievances, nor was there a process to provide written feedback regarding the resolution of such grievances. Additionally, concerns voiced during Resident Council meetings were relayed to administration by the Activity Director through written notes, but there was no established process for communicating responses or resolutions back to the residents. When asked, the DON confirmed that the facility did not have a written grievance policy in place. These failures affected all residents, as there was no formal mechanism to ensure their grievances were addressed and resolved in a timely manner.